Background: We present a case of a 33 year old female with a background of Turners syndrome, adequately managed with growth hormone and oestrogen supplementation, Crohns disease, horse shoe kidney and subclinical hypothyroidism
Case details: She presented to the emergency team with high-grade fever and right sided hemiplegia 10 days following Astra Zeneca COVID vaccination. Initial blood tests showed mildly raised CRP of 49, thrombocytopenia with platelet count of 54 and a normal plain CT head. MRI head showed bilateral multifocal acute infarcts in MCA territory and watershed areas on the left raising a suspicion of a thromboembolic source. She was seen by multiple teams with a working diagnosis of COVID vaccine-induced thrombocytopenic thrombosis. Abdominal and pelvic CT scan was arranged on day 15 of admission on account of persistent pyrexia and raised inflammatory markers. It did not identify focal sepsis but showed ill-defined and enlarged adrenal glands. Soon after the scan she deteriorated acutely with hypotension, hyponatremia and hyperkalaemia, requiring ITU admission. She was treated for suspected acute hypocortisolism with intravenous hydrocortisone and after stabilisation she was initiated on oral hydrocortisone and fludrocortisone. A short synacthen test performed after acute illness, along with ACTH level, confirmed the diagnosis of primary hypocortisolism secondary to bilateral adrenal infarction most likely to be secondary to vaccine-induced thrombocytopenic thrombosis. Repeat CT scan showed resolution of adrenal gland enlargement. She has made moderate recovery from the cerebrovascular episode and continues to be managed with a multidisciplinary team approach in the community. She has received the standard advice regarding long-term steroid use. Oral contraceptive pills were initially stopped as a result of the recent stroke although as she experienced menopausal symptoms she was re-instated on topical HRT patches. There is no plan to withdraw steroids and retest.
Summary: Vaccine related immune thrombocytopenia and thrombosis is a syndrome that has been reported in rare cases after COVID-19 vaccination although this entity is not yet fully understood. Cerebral venous thrombosis is the most common site of thrombosis, with remaining cases affecting a range of sites such as the splanchnic system, heart, lungs, limbs and other solid organs such as adrenal glands and in many cases two or more vascular beds are involved simultaneously. This case highlights the limitation of imaging and importance of clinical signs and symptoms, high index of suspicion in the diagnosis of hypocortisolism.