A life threatening complication of anticoagulation prophylaxis‐bilateral adrenal hemorrhage

Abstract

A 52-year-old man presented to the emergency department (ED) from a skilled nursing facility with a complaint of bilateral upper-quadrant abdominal pain of 48 hours' duration. The pain was sharp, nonradiating, constant, and was associated with nausea, vomiting, and constipation. The patient denied any fever, back pain, dysuria, melena, or hematochezia. In the rehabilitation facility the patient had been initially evaluated for this pain. He was given laxatives and stool softeners for presumed constipation but these measures had not been effective. A computed tomography (CT) scan of the abdomen had only showed stool in the colon and he was sent to the ED for further evaluation.Apart from severe degenerative joint disease in both his knees he was in good health. He was in the skilled nursing facility (SNF) for rehabilitation for bilateral knee replacement surgery done 9 days prior to this presentation. His postoperative course was unremarkable. He had been maintained on prophylaxis for venous thromboembolism with enoxaparin since postoperative day 1 at a daily dose of 40 mg subcutaneously, and was transferred to the SNF on postoperative day 6 on the same dose. His was receiving oxycodone and Tylenol for pain. He was on no other medications.Vital signs on presentation revealed a temperature of 97.5 F, a heart rate of 100 beats per minute, a respiratory rate of 16 breaths per minute, and a blood pressure of 136/ 69 mmHg. He was alert and oriented and in mild distress from the abdominal pain. Examination was normal except for tenderness in the upper quadrants of the abdomen though no rigidity or rebound tenderness were noted. Routine chemistries were normal except for sodium of 134 mg/ dL. His white count, hemoglobin, hematocrit, and platelet levels were noted to be at 17.5K/lL, 10 g/dL, 30%, and 345K/lL, respectively, and were stable with regard to his discharge laboratory values. His serum eosinophil level was normal. A complete workup for hypercoagulable state and bleeding disorders including assays for antibodies associated with heparin-induced thrombocytopenia were negative. He was admitted for further evaluation and treatment. The patient had another CT scan of the abdomen (Figure 1), which when compared to the one done at the SNF 2 days prior showed ''markedly enlarged'' bilateral adrenal glands suggestive of bilateral acute adrenal hemorrhage. The enoxaparin was discontinued and empiric steroid replacement therapy was begun. A random cortisol level was normal but a cosyntropin stimulation test showed an absolute increase in cortisol level of only 0.8 lg/dL at both 30 and 60 minutes after administration of 250 lg of cosyntropin. An investigation was undertaken to determine if the patient had any prior risk factors for bleeding. There was no evidence of infection and a comprehensive evaluation for bleeding, and coagulation disorders was normal. The bilateral adrenal hemorrhage was attributed to the use of enoxaparin in the postoperative setting. Unfortunately, the patient subsequently developed a deep venous thr...

Adrenal Hemorrhage Complicated by Hypertension

“…The differential diagnosis for bilateral adrenal hemorrhage typically includes sepsis (usually secondary to N. Meningitides, P. aeroginosa, E. Coli, and B. Fragilis), antiphospholipid syndrome, heparin-associated thrombocytopenia, warfarin, and severe physiologic stress. 7,8 With the exception of her hypertension, this patient's workup and clinical scenario were highly suggestive of bilateral adrenal hemorrhage secondary to warfarin. The patient was not septic and her platelet count was within normal limits.…”

Adrenal Insufficiency from Unilateral Adrenal Hemorrhage in a Patient on Rivaroxaban Thromboprophylaxis

“…Imaging studies that can identify adrenal hemorrhage include CT, MRI, and ultrasound (5,10,11). Adrenal gland enlargement with signal attenuation greater than that seen with fluid on CT scan is suggestive of adrenal hemorrhage.…”

“…Adrenal gland enlargement with signal attenuation greater than that seen with fluid on CT scan is suggestive of adrenal hemorrhage. A non-enhancing adrenal mass with a high T1 signal intensity visualized on MRI is indicative of adrenal hemorrhage (10,11).…”

“…Historically, the diagnosis had been made in postmortem examinations but the emergence of more sophisticated imaging modalities has allowed for the ability to establish the diagnosis earlier in the clinical course (4). Literature reports of adrenal hemorrhage from the use of anticoagulants has more often been associated with heparin, lowmolecular-weight heparin, and warfarin (5)(6)(7)(8)(9)(10). We present a case of rivaroxaban-induced adrenal hemorrhage with subsequent adrenal insufficiency following total knee arthroplasty.…”

Bilateral adrenal hemorrhage in a total knee patient associated with enoxaparin usage

“…Acute bilateral adrenal hemorrhage (BAH), although rare, has been reported as a potentially catastrophic complication of anticoagulation therapy [1] , [5] , [6] , [7] . However, this condition also occurs in the settings of post-operative period, septicemia, pregnancy, anti-phospholipid syndrome, heparin-associated thrombocytopenia, trauma, and coagulopathies [1] , [5] , [6] , [7] .…”