Adrenal Insufficiency and COVID-19 Vaccination

Patients with adrenal insufficiency who are on glucocorticoid replacement therapy face unique challenges when it comes to vaccination. In most cases, conventional vaccines like those for the influenza virus don't necessitate an increase in glucocorticoid dose. However, with the advent of COVID-19 mRNA vaccines, there have been reported cases of adrenal crisis in patients with secondary adrenal insufficiency. A new paper explores three cases that shed light on this issue. 

Case 1: Idiopathic Isolated ACTH Deficiency

A 78-year-old man with idiopathic isolated ACTH deficiency received the second dose of the BNT162b2 mRNA vaccine. He decided not to take hydrocortisone (HC) on the day of vaccination. The following day, he experienced fatigue, nausea, vomiting, and appetite loss. He did not receive HC and ended up in the emergency department two days later, with severe general fatigue, nausea, vomiting, hyponatremia, and relative hypotension. His symptoms resolved a day after administration of prednisolone sodium succinate (20 mg) IV, followed by HC (100 mg) and saline infusion.

Case 2: Hypopituitarism Post-Craniopharyngioma Surgery

An 80-year-old man with anterior hypopituitarism received the first dose of the BNT162b2 mRNA vaccine. He experienced fatigue and appetite loss the morning after vaccination. Despite being afebrile, he continued his maintenance dose of HC. Five days later, he was admitted to the emergency department with severe symptoms. He was treated with HC (100 mg) IV, followed by HC (100 mg) and continuous saline infusion and felt better three days after. 

Case 3: Idiopathic Isolated ACTH Deficiency with Co-Morbidities

A 79-year-old man with idiopathic isolated ACTH deficiency received the second dose of the BNT162b2 mRNA vaccine. He developed a fever and experienced fatigue and appetite loss. An antipyretic was administered, but his symptoms persisted. A few days later an increased dose of HC (30 mg/d) was administered, following which his symptoms resolved and sodium level normalized. 

These cases highlight the importance of appropriate precautions for patients with adrenal insufficiency when receiving COVID-19 vaccines.

REFERENCE

Kurematsu Y, Mohri T, Okada S, Takahashi Y. Adrenal Crisis Associated With COVID-19 Vaccination in Patients With Adrenal Insufficiency. JCEM Case Rep. 2023 Aug 14;1(4):luad079. doi: 10.1210/jcemcr/luad079. PMCID: PMC10580477.

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