The study characteristics included in this meta-analysis
| Author | Country | Ratio of sex (M/F) | Study design | Sample size | Cortisol (µg/dL) | Outcome | NOS score | ||
| Non-severe | Severe | Non-severe | Severe | ||||||
| Frankel et al 26 | Israel | F | Case report | 1 | – | <1 | – | COVID-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 | UK | M | Case report | – | 1 | – | 26.6 | This study reported that adrenal hemorrhage should be considered as a rare complication of COVID-19 and potentially lethal. | – |
| Etoga et al 7 | Cameroon | 45/35 | Cross-sectional | 70 | 10 | 4.5±0.5 | 11.45±1.8 | This 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 | UAE | M | Case report | 1 | – | 4.6 | – | SARS-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 | Iran | M | Case report | 1 | – | 12 | – | This 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 | Iran | 56/5 | Cohort | 46 | 15 | 21.4±11.2 | 26.2±13.7 | The 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 | Iran | 17/13 | Cross-sectional | 26 | 4 | 26.2±6.5 | 36.1±3.2 | This 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 | Brazil | M | Case series | 16 | 12 | 22.4 | 48.01±21.2 | In 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 | UK | M | Case report | 1 | – | 31.3±2.7 | – | AH and high serum cortisol are rare complications of COVID-19 infection. | – |
| Tan et al
11 | UK | 240/51 | Cohort | 132 | 159 | 22.4±10 | 18.8±8.1 | This study revealed the association between high serum total cortisol concentrations and mortality from COVID-19. | 9 |
| Kumar et al 31 | UK | F | Case report | 1 | – | 21.7 | – | COVID-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.