COVID-19, the ongoing pandemic, has still issues that need to be clarified to manage the disease and its consequences despite of extensive research and several large studies describing the clinical, biochemical, and radiological features. Steroid hormones are commonly classified as glucocorticoids, mineralocorticoids, and sex steroid hormones. Analyzing and monitoring these hormones provides useful information in terms of diagnosis, follow-up, and prognosis of diseases . For this purpose, we analyzed sex steroids, glucocorticoids, and mineralocorticoids simultaneously with LC-MS/MS, a sensitive and specific method, in COVID-19 patients with different disease severity and healthy individuals. According to our literature review, these hormones were evaluated simultaneously in COVID-19 for the first time. Analyzing steroids, whose production is related to each other, in all individuals at the same time, allowed the hormones to be evaluated together and to obtain more reliable data.
SARS-CoV-2 viral entry requires two host proteins: the angiotensin-converting enzyme-2 (ACE2) and the transmembrane protease, serine2 (TMPRSS2). SARS-CoV-2 enters many organs, including endocrine organs, through ACE2 receptors and creates a clinical picture in various spectrums that can change depending on the individual's immune system, age, gender, concomitant diseases, and other unexplained reasons, from mild to severe, and even cause death. Transcription of the TMPRSS2 gene and ACE2 receptor activation are positively regulated by androgens. It is accepted that this situation contributes to the more common and worse prognosis of COVID 19 in men [11, 12]. In our study, we found that the highest androgen levels were in patients with moderate COVID-19. However, we found that as the severity of the disease increased, steroid levels decreased. We attributed this situation to the possibility of high viral load interfering with hormone production, as in the study of Bermejo-Martin et al. in which they compared plasma viral load with disease severity and serum parameters .
There are also opinions supporting that the differences in the severity and mortality of COVID-19 between the sexes are due to immunological and especially hormonal differences, apart from the entry of SARS-CoV-2 into the cell [9, 11]. It has been observed that COVID-19 alters spermatogenesis and testosterone production. In a study by Montaño et al., a negative correlation was found between the severity of COVID-19 and testosterone levels (8). In our study, we also found low testosterone levels in severely ill COVID-19 patients, but we did not find dihydrotestosterone (DHT) levels differently. DHT is a metabolite that results from the reduction of testosterone by 5α-reductase. DHT is a more potent agonist of androgen receptors than testosterone. But its half-life in plasma is shorter than that of testosterone and its levels reflect the local expression of 5α-reductase. Therefore, we think that we could not find DHT levels different in patients with different clinical courses. Due to these differences in studies, there are opinions supporting that innate immunity and genetic errors are more important than the sex steroid levels of individuals in the critical course of COVID-19 .
It is assumed that female sex hormones are potent immunomodulators, and therefore, COVID-19 has a milder clinical course in women . However, in our study, we found lower sex steroid hormone levels in patients with a more severe COVID-19 clinical course. In the comparisons we made according to genders, sex steroids were lower in severe cases than in other patient groups. This may be due to the down-regulation of the gonadal axis by cytokines in patients with acute, severe disease . The results of our study also support this situation.
In an autopsy study conducted on patients with SARS, it was shown that the virus reached the hypothalamus directly through the hematogenous route or directly through the cribriform plate and was destroyed by the identification of the SARS genome in the hypothalamus . In a postmortem study of COVID-19 patients, no significant pathology in adrenal glands was found but areas of necrosis/infarction were seen in one out of the nineteen examined pituitaries . In addition, the hypothalamic-pituitary-testicular axis is also suppressed in acute diseases . In the study of Alzahrani et al., in which they investigated the effect of COVID-19 on the HPA axis, they found no difference between the median values of cortisol in patients with COVID-19 infection of different severity but found low cortisol levels in patients with severe infection . In our study, there were more patients at each COVID-19 patient group than in the study of Alzahrani et al. We found significant differences between the median levels of cortisol and many other steroids between the groups at each severity level, but in severe cases, our steroid levels were low like the mentioned study. In an autopsy study conducted on patients with COVID-19, they observed signs of necrosis, cortical lipid degeneration, hemorrhage, and focal gland inflammation in the adrenal glands associated with infection . This explains the low level of adrenal steroids in patients with severe COVID-19, which we demonstrated in our study.
DHEA is synthesized by zona reticularis of the adrenal cortex from 17 α-hydroxypregnenolone on ACTH stimulation. This androgenic steroid is sulfated to form dehydroepiandrosterone sulfate in the adrenals and peripheral tissues. DHEAS has immunostimulatory effect. DHEA has been found to be more sensitive to HPA axis stimulation than cortisol [20, 21]. However, its relationship with the severity of COVID-19 has not been evaluated. We found that DHEA and DHEAS levels were higher in patients with pneumonia due to the immunostimulatory effect, while they decreased as the severity of the disease increased due to suppression of the HPA axis as the disease progressed. With logistic regression, we determined that with each unit increase in DHEA level, there may be a 1.379 (1.065–1.784)-fold risk increase for COVID-19 disease severity.
Both the cytopathic effect of SARS-CoV-2 virus on the adrenal cortex and secondary adrenal insufficiency caused by ACTH destruction due to the homology of ACTH with viral RNA by antibodies against SARS-CoV-2 have been shown in COVID-19 patients. In addition, stress-induced cortisol increase may be prevented by inadvertent degradation of ACTH by antibodies formed against viral particles [3, 12]. In a study by Gonen et al., they found the frequency of adrenal insufficiency to be 8.2%. They found Antipituitary antibodies (APA) in 3 of these patients who developed adrenal insufficiency and antihypothalamic antibodies (AHA) in 1 of them. They found the cortisol level to be high regardless of the severity of the COVID-19 disease . In our study, cortisol levels were high in patients with moderate severity, but cortisol levels decreased in the group with severe COVID-19 based on the WHO classification for COVID-19. In addition, in many other publications such as Gonen et al., cortisol level was analyzed by electrochemiluminescence immunoassay (ECLIA). We think that one of the reasons for the inconsistency with our results may be due to the difference in the analysis method.
The strength of our study is that the method we used for hormone analysis is sensitive and specific in particularly measuring low hormone concentrations. However, the inability to perform menstrual cycle questioning in female patients is a limitation of our study. In addition, the control group was not matched with the patient group in terms of gender.
In conclusion, this research paper reveals that altered steroid hormon levels has a negative impact on COVID-19 prognosis by smiltaneous measurement of steroid hormones’ levels with LC-MS/MS. Also adrenal insufficiency due to COVID-19 is an endocrinological pathology that should be followed up. By analyzing the steroid hormon levels in with sensitive and specific methods for especially patient’s follow-up, more reliable data will be obtained, and a positive contribution can be made to patient management with early diagnosis and treatment of the pathology that may occur.