Monitoring of Adrenal Functions Amid the COVID-19 Pandemic: Lessons From Pediatric Leukemia

Glucocorticoids are considered the cornerstone of the induction phase in all treatment protocols of acute lymphoblastic leukemia (ALL). Among the adverse effects of high-dose glucocorticoid treatment, adrenal insufficiency is secondary to suppression of the hypothalamic-pituitary-adrenal (HPA) axis. This drawback of exogenous steroid therapy gains a contemporary particular relevance in the current era of the COVID-19 pandemic.

Thirty-two patients with ALL were recruited to participate in this study. Basal cortisol and adrenocorticotropic hormone (ACTH) levels were assessed before induction therapy and re-measured 7 days after steroid cessation. Patients with low cortisol levels were subjected to ACTH stimulation test and were followed up till recovery of ACTH axis.

There was a significant decline in the cortisol levels after completion of glucocorticoids therapy in eight patients (25%), (P<0.000) and it returned to normal levels at the 28th post-induction day (P<0.614). However, two patients showed no response to ACTH testing and received replacement physiologic doses of daily hydrocortisone. A patient had febrile neutropenia and another one developed COVID-19 pneumonia, for both of them high-stress steroid doses have been administered. All the studied patients had normal cortisol levels at the end of the 4-week follow-up period.

We concluded that there might be a beneficial role of testing adrenal reserve in children with ALL; especially those at the maximum period of adrenal suppression. We highly recommend educating patients and families about early symptoms of adrenal insufficiency, assessing adrenocortical functions during the era of the COVID-19 pandemic, and implementing a prompt replacement therapy plan in order to avoid the catastrophic COVID-19-induced cytokine storm.