Bilateral adrenal hemorrhage in antiphospholipid syndrome

Abstract

A 43-year-old man with Hashimoto’s thyroiditis and previous thromboembolic events treated with warfarin for 6 months, presented with right flank pain accompanied with vomiting, dizziness, and altered mental status 2 weeks after discontinuation of warfarin. His clinical examination findings were unremarkable. Routine blood work showed lymphopenia, thrombocytopenia, and hypoosmolar hyponatremia. Random serum cortisol level was low (14 nmol/L). Computed tomography scan of the abdomen revealed bilateral bulky heterogeneous suprarenal gland surrounded by fat stranding representing adrenal hemorrhage. He was treated for acute adrenal crisis and subsequently started on hydrocortisone and fludrocortisone, with significant clinical improvement. His diagnosis was secondary antiphospholipid syndrome (APS) to systemic lupus erythematosus (SLE). Bilateral adrenal thrombosis lead to hemorrhage in the adrenals as a paradoxical effect after warfarin cessation and primarily caused by APS. Bilateral adrenal bleeding should lead to the suspicion of thrombophilic disorders, such as APS, with cautious anticoagulation as the treatment of choice

Lupus anticoagulant hypoprothrombinemia syndrome associated with bilateral adrenal haemorrhage in a child: early diagnosis and intervention

“…The pathophysiology of adrenal gland bleeding remains unclear. The adrenal gland comprises a rich arterial supply with a single vein limiting blood drainage; a thrombosed vein can result in progressive increase in arterial blood pressure [ 12 ].…”

The role of vitamin K in the non-operative management of bilateral adrenal hemorrhage on a background of antiphospholipid syndrome and coagulopathy: a case report

“…Patients with BAH and adrenal infarction will most commonly present with abdominal symptoms (55% of cases). Fever, nausea, vomiting, fatigue and altered sensorium are other symptoms that patients may present with [ 6 ]. The treatment of choice for BAH on a background of APLS as suggested by most authors, is careful anticoagulation therapy with a combination of warfarin and heparin, aiming for a target INR of 2–3 [ 7 ].…”

Adrenal Hemorrhage in Patients with Systemic Lupus Erythematosus and Antiphospholipid Syndrome: A Case Report and Literature Review

“…Pulmonary embolism or deep venous thrombosis was observed in four (18%) patients. In one patient (patient 14), adrenal insufficiency was diagnosed 1 week after inguinal hernia surgery; on the other hand, in two patients, adrenal insufficiency was diagnosed after anticoagulant therapy was discontinued [ 6 , 7 ].…”

“…Nevertheless, among these patients, autoimmune disorders of the adrenal glands could not be eliminated. In one study, a 21-hydroxylase antibody examination could not be conducted, and in another study, four patients were complicated with hypothyroidism [ 6 , 8 ]. The latter finding is vital information for diagnosing the possibility of multiple endocrine organ dysfunction as a result of an autoimmune disorder.…”