TITLE:
Adrenal Crisis Secondary to Bilateral Adrenal Hemorrhage in a Patient with Hypercoagulable Disorder
AUTHORS:
Paola Pedraza-Cruz, Merina Varghese, Dominique DiGiacomo, Caleb T. Spencer, Omar Horani
KEYWORDS:
Bilateral Adrenal Hemorrhage, Adrenal Insufficiency, Antiphospholipid Syndrome, Hypercoagulable State
JOURNAL NAME:
Case Reports in Clinical Medicine,
Vol.14 No.2,
February
20,
2025
ABSTRACT: Background: Bilateral adrenal hemorrhage (BAH) is a rare condition that may lead to life-threatening adrenal insufficiency or adrenal crisis if not addressed appropriately. Case Report: A 54-year-old male with a history of venous thromboembolism (VTE) on warfarin presented to the hospital with nausea, vomiting, and abdominal and flank pain shortly following colonoscopy preparation. Initial imaging of the abdomen and pelvis was notable for hyperdense thickening of the bilateral adrenal glands raising concerns for hemorrhages, and subsequent magnetic resonance imaging (MRI) confirmed BAH. During hospitalization, the patient was placed on prophylactic heparin, and shortly after decompensating, he became tachycardic, hypotensive, and febrile. This led to heparin reversal followed by administration of a single dose of Hydrocortisone 100 mg and Hydrocortisone 50 mg TID due to concern for adrenal insufficiency. The patient also necessitated sepsis work-up and fluid resuscitation. Repeat CT imaging showed no significant change in hemorrhage size bilaterally. Endocrinology, vascular surgery, hematology/oncology, and rheumatology were consulted for the management of adrenal insufficiency, anticoagulation in the presence of hemorrhage, thrombocytopenia, and hypercoagulable state. Towards the end of his hospital course, the patient had asymptomatic diffuse ST elevations, elevated troponin, and an ejection fraction of 10% - 15%, leading to cardiac catheterization and placement of an intra-aortic pump. During subsequent stay in the ICU, the patient developed hemodynamic shock and was transferred to a facility with a higher level of care and medical support therapies. After this transfer, the patient was stabilized from a cardiac standpoint but developed acute respiratory failure suspected to be secondary to diffuse alveolar hemorrhage and immune thrombocytopenic purpura, necessitating platelet transfusion. He was on continued monitoring from rheumatology given his myocarditis believed to be secondary to his antiphospholipid antibodies, and was treated with IVIG, rituximab, and hydroxychloroquine. A repeat echocardiogram revealed an improved ejection fraction of 52% and the patient was then discharged on an enoxaparin bridge to warfarin and a cardiac home event monitor. Discussion: BAH is a life-threatening condition that should be promptly identified and managed in patients presenting with nonspecific symptoms and a history of hypercoagulability or anticoagulation. In these cases, the risk of AH and subsequent adrenal insufficiency is drastically increased, so immediate imaging as well as initiation of steroid therapy is crucial to stabilize patients and prevent adrenal crisis. A multidisciplinary approach, involving endocrinology, hematology, and cardiology as in this case is also imperative to optimize patient outcomes and increase survival. Conclusion: BAH should be considered in patients presenting with a history of VTE and hypercoagulable state when precipitating stressors or predisposing risk factors are present. This case report highlights the importance of clinical awareness of BAH for clinicians to accurately identify and manage it to prevent fatal sequelae and ensure long-term favorable patient outcomes.