P-01 Case report of adrenal insufficiency due to bilateral adrenal hemorage

Abstract

Introduction

Arterial or venous thrombosis may be seen in the presence of antiphospholipid antibody (AFA). Rarely, it can cause adrenal hemorrhage. In this case, a 39-year-old case of adrenal insufficiency due to adrenal hemorrhage accompanied by AFA is presented.

Clinical Case

A 39-year-old male patient with no known disease was admitted to the emergency service with complaints of abdominal pain, general condition disorder, weakness, nausea and vomiting. Hypotension, Na:121meq/L (136-145 meq/L) and K:6.2 meq/L (3.5-5 meq/L), creatinine: 3.56 mg/dl (0.7-1.20), urea: 50.5 mg /dl (6-20), cortisol value measured by suspecting acute adrenal insufficiency was 1.42 µg/dL (5-25 µg/dL), ACTH value was 561 pg/mL (10-46 pg/mL). Abdominal CT for abdominal pain showed a collection area of 58 mm ap diameter on the right and 66 mm ap diameter on the left in both surrenal lobes, and numerous millimeter-sized hypointense areas in the subcapsular area of both kidneys and were evaluated as significant in terms of microinfarcts. Then, areas that were hyperdense in the precontrast series and did not show significant enhancement in the postcontrast series were evaluated for bleeding in adrenal CT (Figure 1).In the tests performed, aPTT 44.5 sec (24-40), C3 1.272 g/dL (0.9-1.8 g/dL), ANA:1/160 homogeneous positive granular, anti-dsDNA:28 IU/mL, lupus anticoagulation positive, in complete urinalysis proteinuria and hyaline cast were detected. The patient was diagnosed with AFAS and systemic lupus erythematosus (SLE), and hydroxychloroquine was started. Warfarin and acetylsalicylic acid were started due to renal vein thrombosis. Stress-dose steroid therapy (80 mg/day methylprednisolone) was started in the patient who was suspected of having adrenal insufficiency due to adrenal hemorrhage. The hemorrhage in our patient was attributed to the hemorrhage caused by the AFA-related infarction. The patient who completed the treatment was discharged with 200 mg hydroxychloroquine, 30 mg hydrocortisone, 0.5 mg fludrocortisone, 5 mg warfarin, 100 mg acetylsalicylic acid, 10 mg amlodipine.

Conclusion

Although the pathogenetic mechanism of adrenal insufficiency seen in AFA syndrome is not fully known; increased coagulation status in these patients is held responsible. Adrenal insufficiency is thought to be due to hemorrhage after venous thrombosis at the adrenal vein or microvascular level. AFA-related adrenal insufficiency is usually permanent and rarely resolves. Therefore, long-term follow-up of these patients is required. The presence of AFA should be investigated in patients presenting with bilateral adrenal hemorrhage.