Special Considerations for Patients With Cushing Syndrome and COVID-19

Patients with Cushing syndrome are at an increased risk for infections due to a compromised immune state. Although there are no data specifically on coronavirus disease 2019 (COVID-19) in patients with Cushing syndrome, it is reasonable to assume they are at increased risk for this viral infection and thus special considerations are needed, according to a commentary published in The Lancet Diabetes & Endocrinology.

The current COVID-19 pandemic has been associated with increased morbidity and mortality risk in patients with various comorbidities, including obesity, diabetes, hypertension, and immunodeficiency, which are all common features in Cushing syndrome.

Patients with Cushing syndrome might present with different and atypical features of COVID-19. Although fever, dyspnea, and cough are the main symptoms associated with severe COVID-19, the febrile response might be attenuated in individuals with Cushing syndrome because of a chronic inflammatory state and poor immune response.

As several risk factors for severe course of COVID-19 are quite common in patients with active Cushing syndrome (i.e., obesity, diabetes, and hypertension), these patients may be more prone to develop acute respiratory distress syndrome (ARDS) and respiratory failure. On the other hand, as cytokine response might be subnormal in patients with Cushing syndrome, it is possible that these patients are less likely to develop severe ARDS with COVID-19.

The risk for thrombembolism might also be increased among patients with Cushing syndrome and COVID-19, as cortisol excess is a known risk factor for hypercoagulability. For that reason, anticoagulant treatment, preferably with low-molecular-weight heparin, is strongly advised for hospitalized patients with Cushing syndrome and COVID-19.

In addition, the healthcare team should consider prolonged antiviral and broad-spectrum antibiotic treatment in these cases, as patients with Cushing syndrome and COVID-19 are at increased risk for prolonged duration of viral and opportunistic infections.

Optimizing glycemic control and blood pressure control are important as impairment of glucose metabolism and hypertension have been found to be negative prognostic factors in COVID-19.

Although surgery is the recommended first-line treatment for Cushing syndrome, in light of the risk associated with surgical intervention during the pandemic and the postoperative immunosuppression and thromboembolic risk, cortisol-lowering medical therapy should be considered as a bridge treatment when cortisol control is required.

The increased risk for COVID-19-associated morbidity and mortality might also apply to patients with Cushing syndrome in remission given that the associated comorbidities related to cortisol excess may persist.

“COVID-19 might have specific clinical presentation, clinical course, and clinical complications in patients who also have Cushing’s syndrome during the active hypercortisolaemic phase, and therefore careful monitoring and specific consideration should be given to this special, susceptible population,” concluded the authors of the commentary.

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

Reference

Pivonello R, Ferrigno R, Isidori AM, Biller BMK, Grossman AB, Colao A. COVID-19 and Cushing’s syndrome: recommendations for a special population with endogenous glucocorticoid excess [published online June 9, 2020]. Lancet Diabetes Endocrinol. doi:10.1016/S2213-8587(20)30215-1