Non-haemorrhagic, bilateral adrenal infarction in a patient with antiphospholipid syndrome along with lupus myocarditis

Abstract

A 40-year-old woman with antiphospholipid syndrome presented with a 5-day history of right upper quadrant (RUQ) pain, radiating posteriorly, associated with fever and vomiting. She was admitted 1-week prior with an upper respiratory infection and erythema multiforme. Clinical assessment revealed sepsis with RUQ tenderness and positive Murphy's sign. Laboratory results showed raised inflammatory markers, along with renal and liver impairment. CT showed bilateral adrenal infarction and inferior vena cava thrombus. The patient was managed for sepsis and started on heparin. Further immunological investigations revealed a diagnosis of systemic lupus erythematous, an exacerbation of which culminated in lupus myocarditis. This case illustrates the importance of promptly recognising adrenal insufficiency in patients with antiphospholipid syndrome and the possible causative agents, which require careful consideration and exclusion to prevent further thrombotic events. It also highlights the importance of undertaking imaging, namely CT, in patients with antiphospholipid syndrome presenting with abdominal pain as well as considering concomitant autoimmune conditions.

Bilateral adrenal hemorrhage in antiphospholipid syndrome

“…This in turn increases arterial blood flow that exceeds the limited venous drainage. 3 Imaging modalities used to visualize adrenal hemorrhage include CT and magnetic resonance imaging. Acute hemorrhage can appear as a hyper-dense mass on CT scan 5 , and cause enlargement of one or both adrenal glands.…”

Bilateral adrenal hemorrhage after colectomy for perforated diverticulitis: A case report

“…The pathophysiology of spontaneous non traumatic adrenal hemorrhage is thought to be related to the vascular anatomy of the adrenals. The adrenal gland has a rich arterial supply in comparison to the venous drainage, which drains into the medullary sinusoids by a few venules and a single vein susceptible to outflow obstruction [ 7 , 8 ].…”

Evolving Adrenal Dysfunction After Bilateral Adrenal Infarction: A Case Report

“…Although adrenal infarction and hemorrhage are rare, there are several case reports of these events in patients with APS (5)(6)(7)(8). In a review of endocrine disorders and APS, PAI due to adrenal infarction/hemorrhage was cited as the most common endocrine manifestation of APS (9).…”