COVID-19 Pneumonia: An Emerging Cause of Syndrome of Inappropriate Antidiuretic Hormone

Severe Hyponatremia in the Setting of COVID-19-Associated Syndrome of Inappropriate Antidiuretic Hormone: A Case Report

The COVID-19 pandemic has resulted in significant worldwide morbidity and mortality. One of the less studied clinical manifestations is Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) associated with COVID-19 pneumonia. We present a single case of COVID-19 pneumonia-associated SIADH in a 71-year-old male with a history of alcohol use disorder. This case highlights the importance of full diagnostic workup of the underlying cause of hyponatremia to avoid significant morbidity.

SIADH & Diabetes insipidus: Neues zu Diagnosestellung und Therapie

COVID-19 und Störungen der Wasser- und Natriumhomöostase Eine Dysnatriämie tritt bei hospitalisierten Patient*innen mit COVID-19 gehäuft auf und ist mit einer erhöhten Mortalität und vermehrt septischen Verläufen assoziiert. Insbesondere eine profunde Hyponatriämie kann auch Ausdruck für ein zugrunde liegendes Syndrom der inadäquaten AVP-Sekretion (SIADH) oder einen Cortisolmangel unter COVID-19-Infektion sein. Patient*innen mit bereits bekannten Störungen des AVP-Systems – wie dem SIADH oder Diabetes insipidus – sind einem erhöhten Risiko einer mitunter schwerwiegenden Elektrolyt-Entgleisung unter COVID-19-Infektion ausgesetzt und sollten engmaschig kontrolliert werden.

Hyponatriämie unter Immun-Checkpoint-Blockade – nicht immer SIADH Der wachsende Einsatz von Immun-Checkpoint-Inhibitoren (ICI) in der Tumortherapie hat auch zu einem Zuwachs von immunvermittelten endokrinen Nebenwirkungen geführt. Diese können zeitlich sehr variabel, auch noch nach Beendigung einer ICI-Therapie, auftreten und initial eine unspezifische Klinik aufweisen. Als ein einfacher, allgemein verfügbarer Biomarker und zugleich sensitives Warnsignal für mögliche endokrine Nebenwirkungen kann die Hyponatriämie dienen. Eine unklare und neu aufgetretene Hyponatriämie unter ICI-Therapie sollte vor Diagnose eines SIADH stets abgeklärt und endokrine Nebenwirkungen sollten ausgeschlossen werden.

Neue Evidenz in der Behandlung der akuten und chronischen Hyponatriämie In der Behandlung der akuten symptomatischen Hyponatriämie eignen sich sowohl die rasche intermittierende Bolusgabe als auch die langsam kontinuierliche Infusion von 3 % NaCl zur Akuttherapie. Die Bolusgabe bietet eine geringe Überlegenheit im Sicherheitsprofil und wird in den Empfehlungen der Europäischen Praxisleitlinie favorisiert. In der Behandlung der chronischen Hyponatriämie bei SIADH ist die Flüssigkeitsrestriktion als Erstlinientherapie ein probates Mittel zur Elektrolyt-Korrektur. Die additive Gabe von Furosemid und NaCl-Kapseln zeigt keine gesteigerte Wirkeffizienz, jedoch eine schlechtere Verträglichkeit.

Copeptin-basierte Diagnostik in der Abklärung des Polyurie-Polydipsie-Syndroms Bei der Abklärung des Polyurie-Polydipsie-Syndroms ist die Sicherung einer hypotonen Polyurie vor der erweiterten diagnostischen Differenzierung essenziell. Copeptin-basierte Testverfahren zeigen eine deutliche Überlegenheit gegenüber dem indirekten Durstversuch in der Differenzierung zwischen Patient*innen mit einem Diabetes insipidus und einer Primären Polydipsie. Das eskalierende Vorgehen der diagnostischen Verfahren ist ebenso zielführend wie ressourceneffizient.

Case Report: Hypothalamic Amenorrhea Following COVID-19 Infection and Review of Literatures

SARS-CoV-2 infection, responsible for the coronavirus disease 2019 (COVID-19), can impair any organ system including endocrine glands. However, hypothalamic-pituitary dysfunctions following SARS-CoV-2 infection remain largely unexplored. We described a case of hypothalamic amenorrhea following SARS-CoV-2 infection in a 36-year-old healthy woman. The diagnostic workup excluded all the causes of secondary amenorrhea, in agreement to the current guidelines, whereas the gonadotropin increase in response to GnRH analogue tests was suggestive for hypothalamic impairment. Therefore, since our patient did not present any organic cause of hypothalamic-pituitary disorder, we hypothesized that her hypothalamic deficiency may have been a consequence of SARS-CoV-2 infection. This assumption, besides on the temporal consecutio, is strengthened by the fact that SARS-CoV-2 infection can impair the hypothalamic circuits, altering the endocrine axes, given that angiotensin-converting enzyme 2 receptors have also been observed in the hypothalamus. We reviewed the literature regarding hypothalamic-pituitary dysfunction in patients with SARS-CoV-2 infection. No study has previously described female hypogonadotropic hypogonadism with secondary amenorrhea following COVID-19. We suggest clinicians focusing greater attention on this possible endocrine disorder.

Prevalence and outcomes of hyponatremia among COVID-19 patients: A systematic review and meta-analysis

Objectives

On March 2020, the WHO declared coronavirus disease 2019 (COVID-19) pandemic. COVID-19 is associated with various clinical syndromes, with electrolytes imbalances involved. This review aims to quantify the prevalence and outcomes of hyponatremia among COVID-19 patients, as well as to review the underlying pathophysiological mechanisms of hyponatremia among these patients.

Methods

Using Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines, we conducted a systematic literature search using the electronic databases of Google Scholar, MEDLINE (PubMed), WHO Virtual Health Library, and ScienceDirect, without limitations regarding gender, geographical area, race or publication date, up until December 13, 2021. Primary outcomes measured were mortality, intensive care unit (ICU) admission, assisted ventilation need, and length of hospital stay (LOS). Secondary outcome was the mechanism underlying hyponatremia among COVID-19 patients.

Results

From a total of 52 included studies, 23 underwent quantitative analysis. For the primary outcomes; proportions, odds ratios (OR), and standardized mean difference (SMD) were calculated using random effects model. The prevalence of hyponatremia was found to be 25.8%. Hyponatremia was found to be significantly associated with increased odds for mortality (OR = 1.97[95% CI, 1.50-2.59]), ICU admission (OR = 1.91 [95% CI, 1.56-2.35]), assisted ventilation need (OR = 2.04 [95% CI, 1.73-2.38]), and with increased LOS (SMD of 5.74 h [95% CI, 0.092-0.385]). Regarding the mechanisms underlying hyponatremia, syndrome of inappropriate anti-diuretic hormone secretion (SIADH) was most commonly reported, followed by adrenal insufficiency, and finally hypovolemic hyponatremia due to gastrointestinal losses.

Conclusion

Hyponatremia among COVID-19 patients is generally associated with poor outcomes, with SIADH being the most common underlying mechanism.

COVID-19 and the pituitary

BACKGROUND

Despite COVID-19 being identified as severe respiratory viral infection, progressively many relevant endocrine manifestations have been reported greatly contributing to the severity of the clinical presentation. Systemic involvement in COVID-19 is due to the ubiquitous expression of angiotensin-converting enzyme 2 (ACE2) receptor, responsible for the entry in the cells of SARS-CoV-2, Several reports in humans and animal models showed a significant ACE2 mRNA expression in hypothalamus and pituitary cells. Moreover, higher mortality and poorer outcomes have been widely described in COVID-19 patients with obesity, diabetes and vertebral fractures, which are all highly prevalent in subjects with pituitary dysfunctions.

AIM

To review the main endocrine manifestations of COVID-19 with their possible implications for pituitary diseases, the possible direct and indirect involvement of the pituitary gland in COVID-19, the impact of COVID-19 on the management of established pituitary diseases which can be already at increased risk for worse outcomes and on neurosurgical activities as well as vaccination.

CONCLUSIONS

Our review underlines that there could be a specific involvement of the pituitary gland which fits into a progressively shaping endocrine phenotype of COVID-19. Moreover, the care for pituitary diseases need to continue despite the restrictions due to the emergency. Several pituitary diseases, such as hypopituitarism and Cushing disease, or due to frequent comorbidities such as diabetes may be a risk factor for severe COVID-19 in affected patients. There is the urgent need to collect in international multicentric efforts data on all these aspects of the pituitary involvement in the pandemic in order to issue evidence driven recommendations for the management of pituitary patients in the persistent COVID-19 emergency.

Hypertension and Electrolyte Disorders in Patients with COVID-19

The worldwide coronavirus disease 2019 (COVID-19) pandemic is still in progress, but much remains unknown about the disease. In this article, we review the association of hypertension or the renin-angiotensin system (RAS) with COVID-19 and the correlation between electrolyte disorders and disease severity. Underlying hypertension is likely to be associated with severe or critical COVID-19, but the relationship is not clear owing to confounding factors. Angiotensin-converting enzyme 2 (ACE2) plays an important role in the non-classical RAS pathway and binds to a receptor binding domain of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The RAS blockade is known to increase ACE2 levels, but controversy remains regarding the effect of RAS blockade therapy in the course of COVID-19. Some reports have indicated a protective effect of RAS blockade on COVID-19, whereas others have reported an association of RAS blockade therapy with the occurrence of severe complications such as acute kidney injury and admission to the intensive care unit. Electrolyte disorders are not uncommon in patients with COVID-19, and severe COVID-19 has frequently shown hypokalemia, hyponatremia, and hypocalcemia. Electrolyte imbalances are caused by alteration of RAS, gastrointestinal loss, effects of proinflammatory cytokines, and renal tubular dysfunction by the invasion of SARS-CoV-2.