Monitoring of Adrenal Function in Children with Acute Lymphoblastic Leukemia: Is it Mandatory amid the COVID-۱۹ Pandemic?

Objectives: 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 is adrenal insufficiency secondary to suppression of the hypothalamic-pituitary-adrenal (HPA) axis. This drawback of exogenous steroid therapy gains a contemporary particular relevance at the current era of COVID-۱۹ pandemic. Design: Prospective. Patients: Thirty-two patients with ALL were recruited to participate in this study. Interventions: Basal cortisol and ACTH levels were assessed before induction therapy and re-measured ۷ days after steroid cessation. Patients with low cortisol were subjected to ACTH stimulation test with follow-up until recovery of ACTH axis. Results:  There was a significant decline in the cortisol levels after completion of glucocorticoids therapy in ۸ patients (۲۵%), (P < ۰.۰۰۰) and returned to normal at day ۲۸ post induction (P < ۰.۶۱۴). However, two of them showed no response to ACTH testing and received replacement physiologic doses of daily hydrocortisone and high stress doses when one had febrile neutropenia sepsis and the other one had COVID-۱۹ pneumonia. All the study patients had normal cortisol levels at the end of ۴ weeks F/U period. Conclusion: We concluded that there might be a beneficial role of testing adrenal reserve in children with ALL especially sick patients at the maximum period of adrenal suppression. We highly recommend assessing adrenocortical functions routinely during the era of COVID-۱۹ pandemic and implementing a prompt replacement therapy plan in order to avoid the catastrophic COVID-۱۹-induced cytokine storm.  

Keywords:

Paediatrics , Endocrinology , Acute Lymphoblastic Leukemia.