Evolving Adrenal Dysfunction After Bilateral Adrenal Infarction: A Case Report

Abstract

Objective: To describe a case of sequential bilateral adrenal infarction and hemorrhage resulting in an unusual pattern of adrenal function over time. Methods: A 50-year-old male with autoimmune antiphospholipid syndrome (APS) presented to the emergency room with severe abdominal pain. Diagnostic studies performed included contrast-enhanced computerized tomographic (IV-CT) imaging of abdomen and pelvis, and laboratory assessment of the hypothalamic-pituitary-adrenal axis. Results: IV-CT of abdomen and pelvis on day 1 showed acute left adrenal gland infarction; cortisol level was 19.9 μg/dL and serum sodium was 133 mEq/L. The patient subsequently developed hyponatremia and hypotension. Repeat IV-CT of abdomen and pelvis on day 3 showed hemorrhagic conversion of the left infarcted adrenal gland and a new right adrenal gland infarction. Cosyntropin stimulation test (CST) confirmed primary glucocorticoid insufficiency. Plasma renin activity and the serum aldosterone level were within normal limits with normokalemia. At 7-month follow-up, CST demonstrated cortisol and aldosterone deficiency. Conclusion: Adrenal infarction is a rare complication of APS but is the most common endocrine complication. Evidence of bilateral adrenal infarction on imaging does not predict the type of adrenal dysfunction that might ensue, as demonstrated in this case. Thorough evaluation of glucocorticoid, mineralocorticoid, and androgen deficiency should be conducted both at the time of the event and in follow-up.

Adrenal Infarction in Pregnancy Secondary to Elevated Plasma Factor VIII Activity

“…These reports all propose that adrenal vein thrombosis is the initial insult to the adrenal gland, especially in the setting of a hypercoagulable state such as antiphospholipid antibody syndrome (APS), followed by hemorrhagic infarction. However, hemorrhage might not always occur [ 5 ]. One case reported the cause of unilateral adrenal infarction in pregnancy to be a complication of APS [ 2 ].…”

“…It is possible that this patient already had some degree of depressed adrenal function, and that when compounded by an acute adrenal infarction, had insufficient time for the contralateral adrenal gland to compensate. The acute loss of function of her unilaterally functioning adrenal gland could have led to a substantial enough decline in production capacity to cause an abnormal response to cosyntropin stimulation [ 5 ].…”

“…Specifically, there should be consideration of risk conversion to adrenal hemorrhage and the risk of bleeding that can occur with vaginal or cesarean deliveries. Anticoagulation for adrenal infarction is recommended in the absence of hemorrhage [ 5 ].…”

A case of adrenal infarction in a patient with COVID 19 infection

“…Prior reports have all suggested that adrenal vein thrombosis secondary to a hypercoagulable state is the initial mechanism leading to adrenal infarction. 12 It may also be related to microvascular thrombosis in the adrenal parenchyma. This is often complicated by haemorrhage due to secondary adrenal necrosis and/or reperfusion injury or anticoagulant therapy.…”

Can COVID-19 lead to Addison’s disease in individual living with HIV? A case report and literature review

“…Adrenal glands are supplied by multiple arterioles supplied by three main arteries (the inferior phrenic, aorta, and renal artery), whereas there is only a single suprarenal vein to drain the glands. [ 15 ] SARS-CoV utilizes angiotensin-converting enzyme 2 (ACE2) as crucial portals for cellular entry. The virus creates a potential prothrombotic state by causing direct damage to endothelial cells via down-regulation of ACE2 and consequently inhibiting mitochondrial functions.…”