DOCSLIB.ORG

Heparin-Induced Thrombocytopenia Presenting As Splenic Hemorrhage Following Cardiac Surgery: a Case Report J Ferry1*, S Youssef2, P WU2 and L Hegerova3

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Heparin-Induced Thrombocytopenia Presenting As Splenic Hemorrhage Following Cardiac Surgery: a Case Report J Ferry1*, S Youssef2, P WU2 and L Hegerova3 ISSN: 2469-5696 Ferry et al. Int J Blood Res Disord 2020, 7:049 DOI: 10.23937/2469-5696/1410049 International Journal of Volume 7 | Issue 1 Open Access Blood Research and Disorders CASE REPORT Heparin-Induced Thrombocytopenia Presenting as Splenic Hemorrhage Following Cardiac Surgery: A Case Report J Ferry1*, S Youssef2, P WU2 and L Hegerova3 1Department of Hematology and Oncology, Swedish Medical Center, Seattle, WA, USA Check for 2Swedish Heart and Vascular – Cardiac Surgery, Seattle, WA, USA updates 3Swedish Center for Blood Disorders and Stem Cell Transplantation, Seattle, WA, USA *Corresponding author: Joseph Ferry, Department of Hematology and Oncology, Swedish Medical Center, Seattle, WA, USA Essentials these patients will develop clinical HIT manifesting with • HIT-associated antibodies are frequently detected after cardiac thrombocytopenia with or without thrombosis [2,3]. surgery. HIT typically presents 5-10 days following exposure to • We report a case of atraumatic splenic hemorrhage due to HIT heparin, often with platelet decline greater than 50% of following coronary artery bypass grafting. baseline and is associated with life and limb threaten- • HIT should be suspected for any patient with congestive hem- ing thrombotic complications. HIT should be suspected orrhage following venous thrombosis, thrombocytopenia and in any patient who has received heparin and develops recent heparin exposure. thrombocytopenia, given high mortality (5-10%) typi- • Hemorrhagic splenic infarction due to splenic vein thrombosis is reminiscent of bilateral adrenal hemorrhage (BAH) due to cally a result of thrombotic complications [1]. adrenal necrosis seen in HIT. One increasingly recognized and unusual thrombot- Abstract ic complication seen in HIT is adrenal vein thrombosis Heparin induced thrombocytopenia with thrombosis (HIT) is a par- with tissue necrosis leading to bilateral adrenal hem- adoxical prothrombotic complication of anticoagulant therapy. We report a case of atraumatic splenic hemorrhage due to splenic vein orrhage (BAH). This congestive hemorrhage following thrombosis as main indicator to diagnosis of HIT. The presentation venous thrombosis should raise high clinical suspicion is reminiscent of the rare bilateral adrenal hemorrhage due to adre- for HIT. We present a case of splenic vein thrombosis nal necrosis that occurs in HIT. Alternative anticoagulation is main- stay of therapy for HIT despite hemorrhage, given the underlying post-cardiac surgery complicated hemorrhagic infarct, acquired hypercoagulability. reminiscent of that seen in BAH, that led to diagnosis Keywords of HIT. Bilateral adrenal hemorrhage, Heparin, Splenic infarction, Throm- Case Report bocytopenia, Thrombosis A 62-year-old woman with a history of congestive Introduction heart failure, coronary artery disease, diabetes mellitus type 2, and recent coronary artery bypass graft (CABG) Heparin-induced thrombocytopenia (HIT) is a com- presented to the emergency department with acute plication of heparin therapy which occurs more com- weakness, dizziness, and malaise. monly in postoperative than medical patients [1]. Up to 50% of patients undergoing cardiac surgery develop an- Past surgery history was significant for a two-vessel tibodies to platelet factor 4 (PF4) complexed to heparin, coronary artery bypass graft involving the left internal attributed to platelet activation and high heparin doses mammary artery to the left anterior descending artery during cardiopulmonary bypass [2]. Only 1% to 3% of and the left radial to obtuse marginal artery nine days Citation: Ferry J, Youssef S, WU P, Hegerova L (2020) Heparin-Induced Thrombocytopenia Present- ing as Splenic Hemorrhage Following Cardiac Surgery: A Case Report. Int J Blood Res Disord 7:049. doi.org/10.23937/2469-5696/1410049 Accepted: May 23, 2020: Published: May 25, 2020 Copyright: © 2020 Ferry J, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Ferry et al. Int J Blood Res Disord 2020, 7:049 • Page 1 of 4 • DOI: 10.23937/2469-5696/1410049 ISSN: 2469-5696 prior to presentation. She had no family history of he- 35.0 sec), normal thrombin time (TT), and normal red matological disorders or hypercoagulability. She was on blood cell morphology. low-dose aspirin. Her complete blood count (CBC) was To evaluate for bleeding, a computed tomography normal prior to CABG including platelet count of 268 × (CT) angiogram of the chest, abdomen and pelvis was 103/µL (normal 150-379 × 103/µL) and at hospital dis- ordered and demonstrated filling defects suggestive charge was 174 × 103/µL with post-operative hemato- of right atrial thrombus, splenic vein thrombosis with crit of 36% (normal 37.5%-51%). splenic infarct, and mild to moderate associated he- On physical examination she was afebrile, hypoten- moperitoneum. She denied abdominal trauma. Surgery sive with systolic blood pressure in the 70s, and in rapid service was consulted and concerned about splenic atrial fibrillation with heart rate 120-130s. She denied hemorrhage. Hematology was consulted to evaluate abdominal pain and had a benign abdominal examina- etiology of spontaneous splenic vein thrombosis infarct tion. Laboratory data revealed white blood cell count with associated hemorrhagic infarction. 10.7 × 109L (normal 3.4-10.8 × 109L), hematocrit 19%, Unfortunately, on day of Hematology evaluation and platelet count of 49 × 103/µL. Complete metabolic (post-operative day 10) she developed left-sided weak- panel and lactate were normal. Troponin was elevated ness and balance changes concerning for stroke and at 0.21 ng/mL (normal 0.00-0.07 ng/mL.) Chest X-ray MRI revealed infarct involving the distribution of the was normal. A limited beside echocardiogram demon- right anterior cerebral artery. A transesophageal echo- strated no pericardial effusion. She received intrave- cardiogram revealed large immobile thrombus in the nous fluid resuscitation and transferred to the intensive care unit for further evaluation. right atrium with a second thrombus adjacent to this which was mobile and arising from the left tricuspid Upon arrival to the intensive care unit, she received valve annulus, large thrombus in the left atrial append- 2 units of packed red blood cells with appropriate in- age, and absence of a patent foramen ovale (Figure 1). crease to hematocrit 25% post-transfusion and 1 unit She was not a candidate for thrombolytic therapy due 3 of platelets with increase to 73 × 10 /µL. Further labo- to thrombocytopenia. She was calculated to have a 4Ts ratory evaluation was negative for hemolysis with nor- score of 7. A heparin PF4 IgG antibody was markedly mal lactate dehydrogenase 292 U/L (normal 119-226 positive with 3.290 OD. Serotonin release assay was U/L) and haptoglobin 98 mg/dL (normal 34-200 mg/dL). not done due to high probability of HIT. Lower extremi- A disseminated intravascular coagulopathy (DIC) panel ty ultrasound was negative for thrombosis while upper demonstrated d-dimer of > 40.00 µg/ml (normal <= 0.49 extremity ultrasound showed cephalic vein thrombosis. µg/ml), normal fibrinogen 214 mg/dL (normal 175-475 The patient was diagnosed with heparin induced throm- mg/dL), international normalized ratio INR 1.4 (normal bocytopenia with thrombosis (HITT). 0.9-1.1), pro time (PT) 16.7 sec (normal 12.0-14.4 sec), partial thromboplastin time (PTT 37.3 sec (normal 22.0- Given extensive thrombosis in HIT, anticoagulation Figure 1: Transesophageal Echocardiogram (TEE). White arrow demonstrating immobile right atrial thrombus. Striped arrow demonstrates second mobile thrombus. Grey arrow demonstrates thrombin strands originating from mobile thrombus. Ferry et al. Int J Blood Res Disord 2020, 7:049 • Page 2 of 4 • DOI: 10.23937/2469-5696/1410049 ISSN: 2469-5696 was cautiously started with bivalirudin. She remained sequelae of HIT. Earlier reports discussed spontaneous clinically stable from the intra-abdominal hemorrhage splenic ruptures occurring on heparin anticoagulants and transitioned to warfarin anticoagulation. Platelets [13-16] however did not report on HIT antibody testing. recovered to 108 × 103/µL four days after starting al- One case report had very similar presentation of splenic ternative anticoagulation and greater than 150 ×3 10 / hematoma after cardiac surgery, with splenectomy pa- µL nine days after therapy for HITT initiated. The pa- thology showing multiple fibrin thrombi in the spleen tient had repeat transthoracic echocardiogram after 3 [8]. This pathology confirms our hypothesis of micro- months of warfarin anticoagulation with resolution of thrombi leading to subsequent hemorrhagic conversion intra-cardiac thrombi. She continues on long-term anti- in spleen, as occurs in BAH. coagulation for atrial fibrillation. Early imaging to identify these unusual intra-abdom- Discussion inal thrombotic complications of HIT is encouraged. A case report by Lammering, et al. discuss a case of splenic Heparin induced thrombocytopenia (HIT) is a para- rupture secondary to splenic vein thrombosis resulting doxical prothrombotic syndrome resulting from expo- from HIT, while the discussion focuses on the utility of sure to heparin-containing products [4-7]. HIT-associ- multi-detector-row computed tomography in the rapid ated antibodies are frequently detected after cardiac and accurate diagnosis of HIT related thromboembolic surgery [8]. Thrombosis
Load more

Recommended publications
  • Idiopathic Adrenal Hematoma Mimicking Neoplasia: a Case Report
    Accepted Manuscript Title: IDIOPATHIC ADRENAL HEMATOMA MIMICKING NEOPLASIA: A CASE REPORT Author: Ibrahim˙ Kılınc¸ Ersin G. Dumlu Vedia Ozt¨¨ urk Neslihan C¸ uhacı Serdar Balcı Abdussamed Yalc¸ın Mehmet Kılıc¸ PII: S2210-2612(16)30061-X DOI: http://dx.doi.org/doi:10.1016/j.ijscr.2016.04.003 Reference: IJSCR 1831 To appear in: Received date: 10-1-2016 Revised date: 28-3-2016 Accepted date: 3-4-2016 Please cite this article as: Kilinc¸ Ibrahim,˙ Dumlu Ersin G, Ozt¨ ddoturk Vedia, C¸ uhaci Neslihan, Balci Serdar, Yalc¸in Abdussamed, Kilic¸ Mehmet.IDIOPATHIC ADRENAL HEMATOMA MIMICKING NEOPLASIA: A CASE REPORT.International Journal of Surgery Case Reports http://dx.doi.org/10.1016/j.ijscr.2016.04.003 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. IDIOPATIC ADRENAL HEMATOME MIMICKING NEOPLASIA: A CASE REPORT İbrahim Kılınç1, Ersin G. Dumlu2, Vedia Öztürk3, Neslihan Çuhacı4, Serdar Balcı5, Abdussamed Yalçın2, Mehmet Kılıç2. 1 Department of General Surgery, Atatürk Research and Training Hospital , Ankara, Turkey. 2 Department of General Surgery, Yıldırım Beyazıt University Faculty of Medicine, Ankara, Turkey. 3 Department of Pathology, Atatürk Research and Training Hospital , Ankara, Turkey. 4 Department of Endocrinology, Atatürk Research and Training Hospital , Ankara, Turkey.
    [Show full text]
  • Massive Adrenal Haemorrhage in the Newborn
    Arch Dis Child: first published as 10.1136/adc.34.174.178 on 1 April 1959. Downloaded from MASSIVE ADRENAL HAEMORRHAGE IN THE NEWBORN BY EILEEN E. HILL and JOHN A. WILLIAMS From the Children's Hospital, Birmingham (RECEIVED FOR PUBLICATION AUGUST 12, 1958) Intra-abdominal haemorrhage in the newborn is of the haemorrhage. From a review of the literature a diagnostic and therapeutic challenge; the site of this would appear to be the first newborn infant to the haemorrhage is commonly the liver or adrenal, survive this complication. Twenty-five similar cases rarely the other organs. (Lundquist, 1930; Potter, which ended fatally are tabulated for comparison 1940; Henderson, 1941). If the haemorrhage is (Table 2). profuse it may lead to rupture of the capsule of the Case Report organ and intraperitoneal haemorrhage. In the The mother, weighing 18 st. 10 lb., was admitted to case of adrenal haemorrhage in the newborn most the Birmingham Maternity Hospital at the twenty-seventh authors have concentrated on post-mortem findings, vteek of her eleventh pregnancy becaulse of hypertension. many of the infants being stillborn. The first Her blood was Group 0 Rhesus negative and contained reported case to be successfully treated was that of blocking antibodies. Two previous infants had haemo- Corcoran and Strauss (1924). Since then eight lytic anaemia due to Rhesus incompatibility. The father other surviving infants in whom adrenal haemor- was heterozygous for the Rhesus factor. The mother was in hospital a month, her blood pressure being 160/90, rhage was diagnosed have been described and these she was then discharged and re-admitted at the thirty- cases are tabulated (Table 1).
    [Show full text]
  • The Spectrum of Haemostatic Abnormalities in Glucocorticoid Excess and Defect
    A M Isidori, A B Grossman Glucocorticoids in haemostasis 173:3 R101–R113 Review and others MECHANISMS IN ENDOCRINOLOGY The spectrum of haemostatic abnormalities in glucocorticoid excess and defect Andrea M Isidori1,*, Marianna Minnetti1,2, Emilia Sbardella1, Chiara Graziadio1 and Ashley B Grossman2,* Correspondence should be addressed 1Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico 155, Rome 00161, Italy to A M Isidori or A B Grossman and 2Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Emails Headington, Oxford OX3 7LE, UK [email protected] or *(A M Isidori and A B Grossman contributed equally to this work) ashley.grossman@ ocdem.ox.ac.uk Abstract Glucocorticoids (GCs) target several components of the integrated system that preserves vascular integrity and free blood flow. Cohort studies on Cushing’s syndrome (CS) have revealed increased thromboembolism, but the pathogenesis remains unclear. Lessons from epidemiological data and post-treatment normalisation time suggest a bimodal action with a rapid and reversible effect on coagulation factors and an indirect sustained effect on the vessel wall. The redundancy of the steps that are potentially involved requires a systematic comparison of data from patients with endogenous or exogenous hypercortisolism in the context of either inflammatory or non-inflammatory disorders. A predominant alteration in the intrinsic pathway that includes a remarkable rise in factor VIII and von Willebrand factor (vWF) levels and a reduction in activated partial thromboplastin time appears in the majority of studies on endogenous CS. There may also be a rise in platelets, thromboxane B2, thrombin–antithrombin complexes and fibrinogen (FBG) levels and, above all, impaired fibrinolytic capacity.
    [Show full text]
  • Natural History of Adrenal Haemorrhage in the Newborn
    Arch Dis Child: first published as 10.1136/adc.48.3.183 on 1 March 1973. Downloaded from Archives of Disease in Childhood, 1973, 48, 183. Natural history of adrenal haemorrhage in the newborn JOHN BLACK and DAVID INNES WILLIAMS From The Hospital for Sick Children, London, and the Children's Hospital, Sheffield Black, J., and Williams, D. I. (1973). Archives of Disease in Childhood, 48, 183. Natural history of adrenal haemorrhage in the newborn. 5 cases of unilateral and 3 cases of bilateral haemorrhage are described. Only 1 infant died, from venous thromboses elsewhere. Apart from this case, all had an above average birthweight. Probable predisposing causes apart from large size were fetal hypoxia, septicaemia, thrombocytopenia, coagulation defect, and disseminated thromboembolic disease. The condition must be distinguished from renal vein thrombosis. In the acute stage pyelography shows depression of the kidney on the affected side, with flattening of the upper calyces. Calcification develops rapidly round the periphery of the mass, then slowly contracts into an area of the size and shape of the original gland. Treat- ment is with antibiotics and blood transfusion, with intravenous corticosteroids in severely shocked or bilateral cases. Adrenal insufficiency is rarely found on follow- up even in bilateral cases, but renal hypertension should be looked for. No single cause for the haemorrhage could be discovered, but the preponderance of haemor- rhage into the right adrenal gland is probably due to anatomical differences between the venous drainage of the two sides. copyright. Unilateral or bilateral haemorrhage into the kidney was depressed and the upper calyces were adrenal gland is a common finding in stillbirths flattened (Fig.
    [Show full text]
  • Transarterial Embolisation of Spontaneous Adrenal Pheochromocytoma Rupture Using Polyvinyl Alcohol Particles Pua U, Wong D E S
    Case Report Singapore Med J 2008; 49(5) : e126 Transarterial embolisation of spontaneous adrenal pheochromocytoma rupture using polyvinyl alcohol particles Pua U, Wong D E S ABSTRACT The spontaneous rupture of a phaeochromo- cytoma is a rare and potentially fatal complication. Prompt diagnosis, patient stabilisation and adrenectomy are crucial for survival. However, it is known that adrenectomy performed in the emergency setting is associated with a high mortality rate, in contrast to the negligible mortality rate with elective surgery. We describe transcatheter arterial embolisation (TAE) using polyvinyl alcohol particles (PVA) in restoring haemodynamic stability during an acute phaeochromocytoma rupture in a 67- Fig. 1 Longitudinal US image shows a large round 6.7 cm × 6.6 year-old man to avoid the risks of performing cm right suprarenal mass with mixed echogenicity. Echogenic an emergency adrenectomy. TAE improves the perinephric fluid is also present, suggestive of haemorrhage (not shown). prognosis significantly by prolonging treatment time for patient optimisation and to enable the possibility of elective adrenectomy. To the best CASE REPORT of our knowledge, TAE using PVA in an acute A 67-year-old man was admitted to the emergency phaeochromocytoma rupture has not been department with a one-day history of severe right loin previously reported in the English literature. and back pain, associated with diaphoresis, nausea and vomiting. Clinical examination revealed positive right Keywords: adrenal haemorrhage, embolisation, renal punch and right hypochondrium guarding. Except phaeochromocytoma, polyvinyl alcohol for a raised total white blood cell count of 17 × 109/L on the particles, transcathetic arterial embolisation complete blood count, the rest of the laboratory tests, which Singapore Med J 2008; 49(5): e126-e130 included liver function, renal function, coagulation profile Department and cardiac panel, were normal.
    [Show full text]
  • Adrenal Hematoma Simulating Malignancy in Idiopathic Thrombocytopenic Purpura
    Elmer ress Case Report J Curr Surg. 2015;5(2-3):179-181 Adrenal Hematoma Simulating Malignancy in Idiopathic Thrombocytopenic Purpura Aleksandr A. Reznichenko Abstract tension, diabetes mellitus, hypothyroidism, coronary artery disease, depression, tonsillectomy, cholecystectomy, tubal Unilateral adrenal hemorrhages are unusual and have different etiolo- ligation, colonoscopy, and arthroscopy presented with lower gies. Very rarely adrenal hematoma could be presented as an adrenal gastrointestinal bleed, thrombocytopenia, weakness, petechi- mass and may have features of neoplastic lesion. There have been a al rash and easy bruising. She was diagnosed with ITP and number of case reports on adrenal hematoma that presented as an adrenal was treated with steroids. Her platelets count improved from tumor in the past; however, there were no reports where it was described 50 to 120 and she had colonoscopy with polypectomy. Three in patients with idiopathic thrombocytopenic purpura (ITP). We present months later, she started to have abdominal pain in left upper a patient with ITP and large adrenal mass suspicious for malignancy, quadrant (LUQ) radiating to her back. Abdominal computer which was surgically excised, and turned out to be an adrenal hematoma. tomography (CT) showed 7 × 9 × 6 cm left adrenal mass with calcifications and central and peripheral enhancement with Keywords: Adrenal hemorrhage; Adrenal hematoma; Adrenal mass; IV contrast, highly suspicious for primary adrenal carcinoma Idiopathic thrombocytopenic purpura; Adrenal carcinoma or metastatic disease (Fig. 1). Comprehensive endocrinology evaluation, including plasma and urine aldosterone, plasma renin activity, plasma and urine metanephrines, plasma and urine catecholamines, free cortisol and dehydroepiandroster- Introduction one (DHEAS) did not show hormonally active adrenal tumor.
    [Show full text]
  • Case Report Idiopathic Unilateral Adrenal Haemorrhage and Adrenal Mass: a Case Report and Review of the Literature
    Hindawi Publishing Corporation Case Reports in Surgery Volume 2013, Article ID 567186, 4 pages http://dx.doi.org/10.1155/2013/567186 Case Report Idiopathic Unilateral Adrenal Haemorrhage and Adrenal Mass: A Case Report and Review of the Literature Christos Christoforides, Athanasios Petrou, and Marios Loizou Department of Surgery, Nicosia General Hospital, 29 Patmos Street, Strovolos, 2062 Nicosia, Cyprus Correspondence should be addressed to Christos Christoforides; [email protected] Received 20 February 2013; Accepted 27 March 2013 Academic Editors: T. C¸ olak and M. Gorlitzer Copyright © 2013 Christos Christoforides et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. We report an unusual case of idiopathic unilateral adrenal haemorrhage (AH) in a 55-year-old patient. This rare case had two characteristics that made it worth of report. First, idiopathic adrenal haemorrhage is very uncommon, and second it was presented as a huge, 23 cm diameter and 2,123 gr weight, “silent” adrenal mass. It is important to distinguish a benign lesion like this from a neoplasm, although we were not able to identify it preoperatively and the diagnosis was only made after the excised specimen was examined by a group of experienced histopathologists. Only a few similar published cases, to our knowledge, are described in the worldwide literature and even fewer of this size. 1. Introduction revealed a palpable mass, approximately 20 × 20 cm in size, occupying an area from the upper to the lower right abdomi- Adrenal haemorrhage (AH) is an uncommon condition more nal quadrantus.
    [Show full text]
  • Severe Bilateral Adrenal Hemorrhages in a Newborn Complicated by Persistent Adrenal Insufficiency
    ID: 17-0165 10.1530/EDM-17-0165 N R Zessis and others Bilateral adrenal hemorrhages ID: 17-0165; February 2018 DOI: 10.1530/EDM-17-0165 Severe bilateral adrenal hemorrhages in a newborn complicated by persistent adrenal insufficiency Correspondence Nicholas R Zessis1, Jennifer L Nicholas2 and Stephen I Stone1 should be addressed 1Pediatrics and 2Radiology, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA to S I Stone Email [email protected] Summary Bilateral adrenal hemorrhages rarely occur during the neonatal period and are often associated with traumatic vaginal deliveries. However, the adrenal gland has highly regenerative capabilities and adrenal insufficiency typically resolves over time. We evaluated a newborn female after experiencing fetal macrosomia and a traumatic vaginal delivery. She developed acidosis and acute renal injury. Large adrenal hemorrhages were noted bilaterally on ultrasound, and she was diagnosed with adrenal insufficiency based on characteristic electrolyte changes and a low cortisol (4.2 µg/dL). On follow-up testing, this patient was unable to be weaned off of hydrocortisone or fludrocortisone despite resolution of hemorrhages on ultrasound. Providers should consider bilateral adrenal hemorrhage when evaluating critically ill neonates after a traumatic delivery. In extreme cases, this may be a persistent process. Learning points: • Risk factors for adrenal hemorrhage include fetal macrosomia, traumatic vaginal delivery and critical acidemia. • Signs of adrenal hemorrhage include jaundice, flank mass, skin discoloration or scrotal hematoma. • Adrenal insufficiency often is a transient process when related to adrenal hemorrhage. • Severe adrenal hemorrhages can occur in the absence of symptoms. • Though rare, persistent adrenal insufficiency may occur in extremely severe cases of bilateral adrenal hemorrhage.
    [Show full text]
  • Bilateral Adrenal Haemorrhage in a Critically Ill Patient
    CASE REPORTS Bilateral adrenal haemorrhage in a critically ill patient Christian M Girgis, Louise Cole and Bernard L Champion Clinical record ABSTRACT A 67-year-old woman presented to the emergency depart- Although rare, bilateral adrenal haemorrhage remains a life- ment with a 3-week history of lower abdominal pain and fever. threatening complication of severe infection and prolonged Following an abdominal computed tomography (CT) scan, she critical illness. A 67-year-old woman developed acute was Critdiagnosed Care Resusc with diverticulitisISSN: 1441-2772 and a 1pericolic June abscess, for adrenal haemorrhage in the context of severe systemic which2011 she 13 underwent 2 123-124 surgical resection of the inflamed bowel, infection due to diverticulitis and pericolic abscess. The abscess©Crit drainage Care and formation Resusc of a colostomy.2011 Thereafter, she www.jficm.anzca.edu.au/aaccm/journal/publi- prompt recognition and management of this condition was was cations.htmtransferred to the intensive care unit, where she received an important component of her eventual recovery. inotropicCase andreports ventilatory support over 2 days for the treatment of severe septic shock (Acute Physiology and Chronic Health Crit Care Resusc 2011; 13: 123–124 Evaluation [APACHE] II and Sequential Organ Failure Assess- ment [SOFA] scores, 24 and 7, respectively). The patient made a complete recovery from her critical One day after extubation and cessation of inotropic agents, illness, but her adrenal insufficiency persisted as demon- she became acutely ill with hypotension (blood pressure, 90/ strated by a significantly low baseline cortisol level (90 nmol/ 60mmHg), delirium, hyponatraemia and hyperkalaemia L) 1 month after the initial diagnosis and persistent changes (sodium [Na+], 130mmol/L, reference range [RR], 135– to suggest adrenal haemorrhage on magnetic resonance 145mmol/L; potassium [K+], 5.4mmol/L, RR, 3.5–5.0mmol/L).
    [Show full text]
  • Adrenal Hemorrhage: a Single Center Experience and Literature Review
    Original papers Adrenal hemorrhage: A single center experience and literature review Izabela M. KarwackaA–F, Łukasz ObołończykC–E, Krzysztof SworczakA,C–F Department of Endocrinology and Internal Diseases, Medical University of Gdańsk, Poland A – research concept and design; B – collection and/or assembly of data; C – data analysis and interpretation; D – writing the article; E – critical revision of the article; F – final approval of the article Advances in Clinical and Experimental Medicine, ISSN 1899-5276 (print), ISSN 2451-2680 (online) Adv Clin Exp Med. 2018;27(5):681–687 Address for correspondence Abstract Izabela M. Karwacka E-mail: [email protected] Background. Adrenal hemorrhage (AH) is a rare condition that can lead to acute adrenal insufficiency and may be fatal. The risk factors of AH include focal adrenal lesion, abdominal trauma and anticoagulation therapy. Funding sources None declared The clinical manifestation of AH varies widely; the symptoms may be related to adrenal insufficiency or may reflect multiple organ failure. However, in many cases, the course of AH is asymptomatic. Conflict of interest Objectives. The study is a retrospective analysis of 23 cases of AH, whose aim is to discuss the etiology and None declared the management of selected patients, as well as a literature review. Material and methods. The paper presents a retrospective analysis of 23 patients with AH confirmed Received on October 27, 2016 by radiological and/or pathological examination. Epidemiological data, the results of laboratory tests, and Reviewed on November 18, 2016 Accepted on February 9, 2017 radiological and pathological examinations were included in the analysis. Results. The risk factors of AH were not established in 13 patients, 5 patients had experienced a trauma prior to AH diagnosis, 1 patient was diagnosed with sepsis, 2 patients had concomitant neoplastic disease, and in 2 patients, 2 risk factors were present.
    [Show full text]
  • Bilateral Adrenal Hemorrhage After Hip Arthroplasty
    Wang et al. BMC Urology (2019) 19:106 https://doi.org/10.1186/s12894-019-0536-7 CASE REPORT Open Access Bilateral adrenal hemorrhage after hip arthroplasty: an initially misdiagnosed case Lei Wang1,2, Xiao-fei Wang1,2, Ying-chao Qin3,JiaChen1,2, Cun-hai Shang4, Guo-feng Sun1,2 and Ning-chen Li1,2,5* Abstract Background: Bilateral adrenal hemorrhage (BAH) is a rare but potentially catastrophic condition. Its clinical manifestation is often non-specific and sometimes difficult to be diagnosed in time. Case summary: A 57-year-old woman, who presented with severe fatigue, nausea and vomiting after left hip arthroplasty due to her femoral neck fracture in a local hospital, was transferred to our medical center. Laboratory results revealed significant hyponatremia, low serum cortisol and elevated serum ACTH. Computed tomography (CT) showed a bilateral adrenal mass, measured 3.6 × 2.7 cm on the left and 3.4 × 2.3 cm on the right. Further magnetic resonance imaging (MRI) confirmed the diagnosis of BAH. The patient was prescribed with oral prednisolone acetate, 5 mg, tid, and her condition improved gradually. Nine months after, the patient was in good condition with 5 mg prednisolone acetate per day. CT revealed a clearly shrunken adrenal mass compared with 9 months ago. Conclusions: This case illustrates the difficulty in making the diagnosis of BAH with atypical presentation. Such cases necessitate greater alertness on the part of the clinician and require rapid diagnosis and prompt glucocorticoid replacement for better clinical outcomes. Keywords: Bilateral adrenal hemorrhage, Arthroplasty, Stress, Anticoagulants, Glucocorticoid replacement, Case report Background In this study, we describe a rare case of BAH after Adrenal hemorrhage (AH) is a rare condition with a re- hip arthroplasty in a 57-year-old female with left fem- ported incidence of only 5 in 1,000,000 [1].
    [Show full text]
  • Severe Bilateral Adrenal Hemorrhages in a Newborn Complicated by Persistent Adrenal Insufficiency
    ID: 17-0165 10.1530/EDM-17-0165 N R Zessis and others Bilateral adrenal hemorrhages ID: 17-0165; February 2018 DOI: 10.1530/EDM-17-0165 Severe bilateral adrenal hemorrhages in a newborn complicated by persistent adrenal insufficiency Correspondence Nicholas R Zessis1, Jennifer L Nicholas2 and Stephen I Stone1 should be addressed 1Pediatrics and 2Radiology, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA to S I Stone Email [email protected] Summary Bilateral adrenal hemorrhages rarely occur during the neonatal period and are often associated with traumatic vaginal deliveries. However, the adrenal gland has highly regenerative capabilities and adrenal insufficiency typically resolves over time. We evaluated a newborn female after experiencing fetal macrosomia and a traumatic vaginal delivery. She developed acidosis and acute renal injury. Large adrenal hemorrhages were noted bilaterally on ultrasound, and she was diagnosed with adrenal insufficiency based on characteristic electrolyte changes and a low cortisol (4.2 µg/dL). On follow-up testing, this patient was unable to be weaned off of hydrocortisone or fludrocortisone despite resolution of hemorrhages on ultrasound. Providers should consider bilateral adrenal hemorrhage when evaluating critically ill neonates after a traumatic delivery. In extreme cases, this may be a persistent process. Learning points: • Risk factors for adrenal hemorrhage include fetal macrosomia, traumatic vaginal delivery and critical acidemia. • Signs of adrenal hemorrhage include jaundice, flank mass, skin discoloration or scrotal hematoma. • Adrenal insufficiency often is a transient process when related to adrenal hemorrhage. • Severe adrenal hemorrhages can occur in the absence of symptoms. • Though rare, persistent adrenal insufficiency may occur in extremely severe cases of bilateral adrenal hemorrhage.
    [Show full text]