Category: Adrenal Disorders

Monitor: 19

19 - ACUTE ADRENAL INSUFFICIENCY AS A PRESENTATION OF ANTIPHOSPHOLIPID SYNDROME

Saturday, Apr 27
10:30 AM – 11:00 AM

Objective :

To report a case of a bilateral adrenal hemorrhage due to antiphospholipid syndrome, leading to acute adrenal insufficiency.


Methods :

We describe a 34-year-old male with no known comorbidities who had multiple visits to the emergency department for abdominal pain and constipation. A complete gastrointestinal workup showed a normal CT abdomen/pelvis, upper endoscopy, and colonoscopy. He was initially suspected to have irritable bowel syndrome- constipation predominant, and was prescribed Linaclotide and Amitriptyline to regulate his bowel movements. He continued to have abdominal pain, with new symptoms of nausea, vomiting, increasing fatigue and weight loss. One month later, he was admitted for worsening symptoms, and was found to be hypotensive (80/50 mm Hg). Labs revealed hyponatremia at 120mmol/L (N:135-145mmol/L), which was normal one week ago. MRI abdomen showed significant enlargement of right adrenal gland, concerning for hemorrhage, and decrease in size of left adrenal gland, suggestive of resolving hemorrhage.


Results :

Random cortisol levels done at two occasions were low at 3.71mcg/dl and 3.57mcg/dl. He was diagnosed with acute adrenal insufficiency (AAI) and was started on hydrocortisone and fludrocortisone replacement. Infectious workup for adrenal hemorrhage including tuberculosis quantiferon, EBV, hepatitis panel, RPR, HIV, and fungal studies were negative. He was found to have elevated partial thromboplastin time (PTT), without any correction on mixing studies. Lupus anticoagulant testing done 12 weeks apart was positive. Based on these findings, he was diagnosed as having antiphospholipid syndrome (APS) complicated with AAI due to hemorrhagic infarction. He was recommended lifelong anticoagulation, along with glucocorticoid and mineralocorticoid replacement.


Discussion :

APS presenting as AAI is extremely rare. Bilateral adrenal hemorrhage is a potentially fatal condition, seen in 4.7-6.2 per million in developed countries. The presence of catecholamine surge during stress leading to vasoconstriction and capillary hemorrhage, along with hypercoagulable state present in APS, can together contribute to venous infarction/hemorrhage. Clinical manifestations are not noted until >90% of the adrenal cortex has been destroyed, with abdominal pain and hemodynamic instability being the most common presentation, as was seen in our patient. Adrenal failure can be life-threatening in about 10-26% of these patients and can be the first clinical manifestation of underlying APS.


Conclusion :

AAI due to the APS is a rare but potentially fatal complication, which may precede APS in some cases. A high index of suspicion is needed to make the diagnosis and initiate lifesaving treatment.

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Pallavi Pradeep

Resident Physician
Carle Foundation Hospital/University of Illinois Urbana-Champaign
Urbana, Illinois

Dr. Pallavi Pradeep is a PGY2 internal medicine resident at Carle Foundation Hospital/University of Illinois Urbana-Champaign. She also serves as a faculty for University of Illinois College of medicine and Carle-Illinois College of medicine. She went to medical school in Manipal University, India. Her previous research projects have been in Diabetic foot assessment and practices and nosocomial infections. She has an interest in Endocrinology and is currently involved in research projects related to Diabetes, Nutrition and Obesity.

Saleha Dar

Resident Physician
Carle Foundation Hospital/University of Illinois Urbana-Champaign

Resident Physician PGY-1 at Carle Foundation Hospital/University of Illinois Urbana-Champaign.

Toufic Abdo

Attending Physician
Carle Foundation Hospital/University of Illinois Urbana-Champaign

Dr. Toufic Abdo, MD is an endocrinology, diabetes & metabolism specialist working as an attending physician at Carle Foundation Hospital in Champaign, IL. He graduated from Amer U Beirut in 1997, did his residency in Internal medicine at State University of New York (SUNY) at Buffalo, from 1998-2001. He also did his fellowship in Endocrinology at SUNY from 2008-09.

Pallavi Pradeep

Resident Physician
Carle Foundation Hospital/University of Illinois Urbana-Champaign
Urbana, Illinois

Dr. Pallavi Pradeep is a PGY2 internal medicine resident at Carle Foundation Hospital/University of Illinois Urbana-Champaign. She also serves as a faculty for University of Illinois College of medicine and Carle-Illinois College of medicine. She went to medical school in Manipal University, India. Her previous research projects have been in Diabetic foot assessment and practices and nosocomial infections. She has an interest in Endocrinology and is currently involved in research projects related to Diabetes, Nutrition and Obesity.