INTRODUCTION There is emerging speculation that the inflammatory state associated with SARS-CoV-2 infection may trigger autoimmune conditions, but no causal link is established. There are reports of autoimmune thyroiditis, and adrenal insufficiency in adults post-COVID-19. We describe the first pediatric report of autoimmune adrenal insufficiency and hypothyroidism after COVID-19. CASE PRESENTATION A 14-year-old previously healthy girl, with vitiligo, presented in shock following one-week of fever, lethargy, diarrhea, and vomiting. Three weeks prior, she had congestion and fatigue, and known familial exposure for COVID-19. Labs were remarkable for sodium 129mmol/L, K 4.3mmol/L, creatinine 2.9mg/dL, hemoglobin 8.3 g/dL and positive COVID-19 PCR and SARS CoV-2 IgG. She was resuscitated with normal saline and required pressor support. EKG showed abnormal repolarization presumed secondary to myocarditis. She met criteria for Multisystem Inflammatory Syndrome in Children (MIS-C), received intravenous immune globulin and IL-1R antagonist, and was admitted for intensive care. Persistent hypotension despite improved inflammatory markers, and an undetectable cortisol led to initiation of hydrocortisone. She was then able to rapidly wean off vasopressors and hydrocortisone within 48 hours. Thereafter, tests undertaken for persistent bradycardia confirmed autoimmune hypothyroidism with TSH 131mcunit/ml, freeT4 0.85ng/dL, and positive thyroid autoantibodies. Basal and stimulated cortisol were <1 mcg/dL on a standard 250mcg cosyntropin stimulation test, with baseline ACTH >1250pg/mL confirming primary adrenal insufficiency. Treatment was initiated with hydrocortisone, levothyroxine, and fludrocortisone. Adrenal sonogram did not reveal any hemorrhage and anti-adrenal antibody titers were positive. The family retrospectively reported oligomenorrhea, increased salt craving in the months prior, and family history of autoimmune thyroiditis. The cytokine panel was notably different from other cases of MIS-C. CONCLUSION This is the first pediatric report, to our knowledge, of primary adrenal insufficiency and hypothyroidism following COVID-19, leading to a unique presentation of autoimmune polyglandular syndrome type 2. The initial presentation was attributed to MIS-C, but the subsequent clinical course suggests the possibility of adrenal crisis. It remains unknown if COVID-19 had a causal relationship in triggering the autoimmune adrenal insufficiency and hypothyroidism.
New onset Primary Adrenal Insufficiency and Autoimmune Hypothyroidism in a Pediatric Patient presenting with MIS-C.