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An event is serious (based on the ICH definition) when the patient outcome is:
* death
* life-threatening
* hospitalisation
* disability
* congenital anomaly
* other medically important event
A 79-year-old man developed adrenal insufficiency following off-label treatment with dexamethasone for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection.
The man, who had hypertension, was admitted to the ICU for lung injury associate with the SARS-CoV-2 infection. He had been receiving amlodipine for hypertension. On admission, he was placed on mechanical ventilation. Also, prone positioning with muscular relaxation for 48h was applied. Subsequently, he started receiving off-label treatment dexamethasone 6.6 mg/day [route not stated] for 10 days. Concomitantly, he also received remdesivir for 10 days. His oxygenation improved during prone positioning, while deteriorated again in the supine positioning. After two days of prone positioning therapy, ventilator-associated pneumonia was suspected. Hence, he was treated with cefepime. His oxygenation did not show any changes, while chest X-ray images showed improvement. In spite of pulmonary embolism suspicion, his fibrin degradation product (FDP) level was low without any findings of right ventricular dysfunction. After 10-days of dexamethasone therapy, his treatment was stopped without any tapering or replacement. Twenty hours after discontinuation of dexamethasone, his BP slightly decreased.
Hence, the man received treatment with norepinephrine [noradrenaline] and fluid infusions. Over the following 12h, his haemodynamic status worsened. He also developed hypoglycaemia. In view of unimpaired right ventricular function and low FDP, the embolic complication was ruled out. The chest X-ray showed right dominant pulmonary oedema. Based on findings, a diagnosis of adrenal insufficiency secondary to dexamethasone was made. Hence, he was treated with hydrocortisone, which resulted in the stabilisation of glucose levels and haemodynamics. His oxygenation and chest X-ray findings also improved. However, he died because of progressive respiratory failure.
Reference
- Uemura K, et al. A case of shock after 10 days systemic corticosteroid therapy for COVID-19. JA Clinical Reports 7: No. 1, 8 Jan 2021. Available from: URL: 10.1186/s40981-020-00410-y [DOI] [PMC free article] [PubMed]