Abstract
Patients with primary adrenal insufficiency require stress-dose glucocorticoids during acute illness to prevent adrenal crisis. We report twin patients with von Hippel–Lindau syndrome status post bilateral adrenalectomy who presented concurrently with symptomatic SARS-CoV-2 infection but experienced markedly different clinical courses based on adherence to stress-dose steroid recommendations. Twin 1 appropriately increased her glucocorticoid dose at symptom onset and remained hemodynamically stable, requiring only brief observation before discharge. Twin 2 did not initiate stress dosing and developed adrenal crisis with hypotension, hypoglycemia, and altered mental status, requiring hospitalization and parenteral glucocorticoids. This case highlights the physiologic importance of stress-dose glucocorticoids in patients without adrenal reserve and illustrates the consequences of delayed dose escalation during systemic infection. The contrasting outcomes underscore the critical role of patient education, early recognition of illness, and adherence to sick-day management protocols in reducing preventable morbidity.
Keywords
Adrenal crisis, Glucocorticoid replacement, Stress-dose steroids, Sick-day rules