Rivaroxaban: Acute adrenal crisis secondary to bilateral adrenal haemorrhage: case report

A 75-year-old man developed acute adrenal crisis secondary to bilateral adrenal haemorrhage following treatment with rivaroxaban [Xaeralto].

The man presented with abrupt abdominal pain, altered mental status and weakness. He was receiving 10mg rivaroxaban [route not stated] daily for deep venous thrombosis (DVT) prophylaxis. An abdominal CT revealed non-specific bilateral fat stranding around both adrenal glands. His cortisol level on admission was 48 gg/dL. He was admitted to ICU with differential diagnosis of sepsis, metabolic encephalopathy and questionable bilateral adrenal haemorrhage.

The man received treatment with hydration, antibiotics and hydrocortisone. The treatment with rivaroxaban was changed to low molecular weight heparin [specific drug not stated] for DVT prophylaxis. Subsequently, he developed thrombocytopenia during admission with a positive heparininduced thrombocytopenia. The antibiotic therapy was changed to clindamycin and his platelet count normalised. He did not show adrenal insufficiency or bleeding. He was discharged.

The man again received treatment with rivaroxaban. He was re-admitted to the ICU for hypovolaemic shock. He was intubated and placed on antibiotics, vasopressors. His cortisol level was 0.9 gg/dL and adrenal insufficiency was again considered. Abdominal CT scan showed interval development of bilateral adrenal nodules suggestive of haematomas. He showed a remarkable improvement after treatment with hydrocortisone. A diagnosis of acute adrenal crisis secondary to bilateral adrenal haemorrhage was made [duration of treatment to reaction onset not stated].

Author comment: "To our knowledge, this is the first case of bilateral adrenaJ haemorrhage secondary to Rivaroxaban (Xaeralto)."

Machhadieh B, et al. Bilateral adrenal hemorrhage presenting with delayed adrenal crisis in a patient on rivaroxaban (Xaeralto). Endocrine Reviews 36: No. 2, Apr 2015. Available from: URL: https://endo.confex.com/endo/2015endo/webprogram/ Paper21958.html [abstract] - USA 803216520