Table 1

The study characteristics included in this meta-analysis

AuthorCountryRatio of
sex (M/F)
Study designSample sizeCortisol (µg/dL)OutcomeNOS score
Frankel et al 26 IsraelFCase report1<1COVID-19 infection is associated with BAH. Adrenal insufficiency is life-threatening, therefore we suggest considering performing early adrenal axis testing for patients with COVID-19 with clinical suspicion of adrenal insufficiency.
Elkhouly et al 27 UKMCase report126.6This study reported that adrenal hemorrhage should be considered as a rare complication of COVID-19 and potentially lethal.
Etoga et al 7 Cameroon45/35Cross-sectional70104.5±0.511.45±1.8This study recorded higher levels of cortisol among COVID-19 cases that need further oxygen therapy than those with mild condition.8
Hashim et al 28 UAEMCase report14.6SARS-CoV-2 can knock down the host’s cortisol stress response and clinicians must be vigilant about the possibility of an underlying relative cortisol deficiency in patients with COVID-19.
Heidarpour et al 29 IranMCase report112This study suggested that early detection of adrenal insufficiency among critically ill patients infected with SARS-CoV-2 could be lifesaving.
Vaez Mahdavi et al 10 Iran56/5Cohort461521.4±11.226.2±13.7The current study results support that COVID-19 affects the patients’ body via mechanisms related to the effects of DHEA-S and cortisol.9
Ramezani et al 24 Iran17/13Cross-sectional26426.2±6.536.1±3.2This study significantly correlated higher levels of cortisol in non-survived patients of COVID-19 in comparison with surviving patients.8
Freire Santana et al 6 BrazilMCase series161222.448.01±21.2In this study, adrenal lesions are frequent in patients with severe COVID-19. No cortisol level less than 10 µg/dL, which is a reliable and widely available laboratorial marker of adrenal insufficiency in critically ill patients, could contribute to the lethal outcome.
Sharrack et al 30 UKMCase report131.3±2.7AH and high serum cortisol are rare complications of COVID-19 infection.
Tan et al
UK240/51Cohort13215922.4±1018.8±8.1This study revealed the association between high serum total cortisol concentrations and mortality from COVID-19.9
Kumar et al 31 UKFCase report121.7COVID-19 creates a hypercoagulable state, with acute adrenal infraction as a possible prothrombotic complication.
  • AH, adrenal hemorrhage; BAH, bilateral adrenal hemorrhage; DHEA-S, dehydroepiandrosterone-sulfated form; F, female; M, male; NOS, Newcastle–Ottawa Scale.