Unmasking Adrenal Insufficiency in COVID-19: The Diagnostic Challenge of Concomitant Acute Kidney Injury and High Ileostomy Output.

BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic has elucidated various extrapulmonary manifestations of severe acute respiratory syndrome coronavirus 2, including endocrine complications that affect the hypothalamic-pituitary-adrenal axis. Efforts to diagnose adrenal insufficiency in critically ill patients are challenging due to overlapping symptoms such as hypotension and fatigue. This challenge is amplified in patients with renal comorbidities, among whom classic electrolyte derangements of adrenal insufficiency (eg, hyperkalemia) may be masked by acute kidney injury (AKI) and renal replacement therapy. CASE REPORT A 46-year-old man with chronic kidney disease and an ileostomy presented with fatigue, abdominal pain, high ileostomy output, and hypotension. Evaluation revealed COVID-19 with concomitant AKI, metabolic acidosis, and hyperkalemia. Initial management via hemodialysis and remdesivir corrected the acidosis and electrolyte abnormalities. However, after renal recovery and discontinuation of dialysis, the patient developed recurrent, refractory hypotension, hyperkalemia, and hypoglycemia, prompting assessment for adrenal dysfunction. Morning cortisol levels were critically low. A subsequent cosyntropin stimulation test showed a blunted cortisol response, confirming adrenal insufficiency. Hydrocortisone and fludrocortisone treatments resulted in hemodynamic stabilization and resolution of the electrolyte abnormalities. CONCLUSIONS This case highlights the "masking" effect of dialysis on the clinical presentation of adrenal insufficiency. Clinicians must maintain a high index of suspicion for adrenal insufficiency in patients with COVID-19 who display recurrent hypotension or hyperkalemia despite renal recovery. Furthermore, the presence of hyperkalemia in a patient with high ileostomy output is paradoxical and should prompt immediate evaluation for mineralocorticoid deficiency.