warfarin and Adrenal-Gland-Diseases

Two patients developed catastrophic multicentric skin necrosis while receiving warfarin to treat venous thromboembolism complicated by immune-mediated heparin-induced thrombocytopenia (HIT). Patient 1 developed skin necrosis involving the breasts, thighs, and face, as well as venous limb gangrene and bilateral hemorrhagic necrosis of the adrenal glands, resulting in death. The second patient developed bilateral mammary necrosis necessitating mastectomies, as well as skin necrosis involving the thigh. Neither patient had an identifiable hypercoagulable syndrome, other than HIT. HIT may represent a risk factor for the development of multicentric warfarin-induced skin necrosis (WISN).

Topics: Adrenal Gland Diseases; Aged; Amputation, Surgical; Anticoagulants; Antigens, Human Platelet; Autoantibodies; Autoimmune Diseases; Databases, Factual; Disseminated Intravascular Coagulation; Ecchymosis; Fatal Outcome; Female; Gangrene; Hemorrhage; Heparin; Humans; Mastectomy; Middle Aged; Multiple Organ Failure; Necrosis; Postoperative Complications; Pulmonary Embolism; Skin; Skin Diseases; Thigh; Thrombin; Thrombocytopenia; Thrombophilia; Thrombophlebitis; Vena Cava Filters; Warfarin

Antiphospholipid syndrome (APS) is an uncommon autoantibody-mediated condition characterised by acquired thrombophilia resulting in recurrent arterial and venous thrombosis. An inciting factor allows for the exposure of endothelial phospholipids, causing antigen formation and subsequent creation of antibodies. A woman in her 70s presented after vehicular trauma, suffering broken ribs, pneumothorax and incidentally discovered left adrenal haemorrhage. Two weeks later she presented with acute-onset abdominal pain and was found to have a right adrenal gland haemorrhage on CT imaging without interval trauma occurring. The patient had antiphospholipid antibody laboratory studies drawn and was given intravenous heparin with a bridge to warfarin at discharge. Laboratory results returned positive for lupus anticoagulant, beta-2 glycoprotein and anticardiolipin antibodies indicating triple positivity, with repeated laboratory tests positive in 12 weeks' time, confirming the diagnosis. Bilateral adrenal haemorrhage, rather than traditional venous thromboembolism, was the presenting pathology in this patient's diagnosis of APS.

Topics: Adrenal Gland Diseases; Antibodies, Anticardiolipin; Antibodies, Antiphospholipid; Antiphospholipid Syndrome; Female; Glycoproteins; Hemorrhage; Heparin; Humans; Lupus Coagulation Inhibitor; Phospholipids; Warfarin

Topics: Adrenal Gland Diseases; Anticoagulants; Antiphospholipid Syndrome; Female; Hemorrhage; Humans; Middle Aged; Warfarin

A 46-year-old man with antiphospholipid syndrome (APS) and previous pulmonary embolism on anticoagulation with rivaroxaban was brought in to the hospital after a syncopal episode. He was found to be hypotensive and tachycardic and later admitted to the intensive care unit. Clinical presentation and laboratory findings were consistent with adrenal insufficiency. MRI revealed bilateral adrenal haemorrhage and he received appropriate steroid replacement therapy. Symptoms slowly subsided and anticoagulation regimen was changed to warfarin. Adrenal haemorrhage was likely caused by APS and rivaroxaban, which brings into question whether novel oral anticoagulants are safe in this patient population.

Topics: Adrenal Gland Diseases; Adrenal Insufficiency; Anticoagulants; Antiphospholipid Syndrome; Hemorrhage; Heparin; Humans; Male; Middle Aged; Pulmonary Embolism; Rivaroxaban; Treatment Outcome; Warfarin

Sepsis is a syndrome of life-threatening organ dysfunction caused by a dysregulated host response to infection. It can have devastating consequences, including bilateral adrenal hemorrhage, particularly in patients at high thrombotic risk, such as those with antiphospholipid syndrome and those on long-term anticoagulation.. A 49-year-old white woman re-presented to hospital with a history suggestive of sepsis. She had a medical background of primary antiphospholipid syndrome on lifelong warfarin. Ten days prior to this presentation, she had been hospitalized following Escherichia coli bacteremia, commenced on intravenous antibiotics, and discharged 2 days later with a prescribed 5-day course of oral amoxicillin. On readmission, she had ongoing fever, myalgia, malaise, and hypotension. Investigations revealed anemia with thrombocytopenia, hyponatremia, and acute-on-chronic kidney injury. Despite treatment for urosepsis, she became tachypneic, clammy, light-headed, drowsy, and hypothermic. Computed tomography revealed bilateral adrenal hemorrhage, and biochemical examination confirmed hypoadrenalism. Following discharge, she had persistent renal and hepatic injury lasting 3 months.. Early identification, intensive monitoring, and aggressive support may reduce the acquired thrombotic risk and avoid potentially life-threatening outcomes of sepsis.

Topics: Abdominal Pain; Adrenal Gland Diseases; Adrenal Glands; Adrenal Insufficiency; Anti-Bacterial Agents; Anti-Inflammatory Agents; Antiphospholipid Syndrome; Diarrhea; Escherichia coli; Female; Hemorrhage; Humans; Hydrocortisone; Middle Aged; Sepsis; Tomography, X-Ray Computed; Treatment Outcome; Vomiting; Warfarin

The increased risk of hemorrhage associated with anticoagulant therapy following traumatic brain injury creates a serious dilemma for medical management of older patients: Should anticoagulant therapy be resumed after traumatic brain injury, and if so, when?. To estimate the risk of thrombotic and hemorrhagic events associated with warfarin therapy resumption following traumatic brain injury.. Retrospective analysis of administrative claims data for Medicare beneficiaries aged at least 65 years hospitalized for traumatic brain injury during 2006 through 2009 who received warfarin in the month prior to injury (n = 10,782).. Warfarin use in each 30-day period following discharge after hospitalization for traumatic brain injury.. The primary outcomes were hemorrhagic and thrombotic events following discharge after hospitalization for traumatic brain injury. Hemorrhagic events were defined on inpatient claims using International Classification of Diseases, Ninth Revision, Clinical Modification codes and included hemorrhagic stroke, upper gastrointestinal bleeding, adrenal hemorrhage, and other hemorrhage. Thrombotic events included ischemic stroke, pulmonary embolism, deep venous thrombosis, and myocardial infarction. A composite of hemorrhagic or ischemic stroke was a secondary outcome.. Medicare beneficiaries with traumatic brain injury were predominantly female (64%) and white (92%), with a mean (SD) age of 81.3 (7.3) years, and 82% had atrial fibrillation. Over the 12 months following hospital discharge, 55% received warfarin during 1 or more 30-day periods. We examined the lagged effect of warfarin use on outcomes in the following period. Warfarin use in the prior period was associated with decreased risk of thrombotic events (relative risk [RR], 0.77 [95% CI, 0.67-0.88]) and increased risk of hemorrhagic events (RR, 1.51 [95% CI, 1.29-1.78]). Warfarin use in the prior period was associated with decreased risk of hemorrhagic or ischemic stroke (RR, 0.83 [95% CI, 0.72-0.96]).. Results from this study suggest that despite increased risk of hemorrhage, there is a net benefit for most patients receiving anticoagulation therapy, in terms of a reduction in risk of stroke, from warfarin therapy resumption following discharge after hospitalization for traumatic brain injury.

Topics: Adrenal Gland Diseases; Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Brain Injuries; Brain Ischemia; Female; Gastrointestinal Hemorrhage; Hemorrhage; Humans; Intracranial Hemorrhages; Male; Myocardial Infarction; Pulmonary Embolism; Retrospective Studies; Risk Assessment; Stroke; Thrombosis; Venous Thrombosis; Warfarin

Adrenal haemorrhage (AH) is a rare but potentially devastating complication of heparin-induced thrombocytopenia (HIT). Neither the prevalence nor the natural history of AH due to HIT are known. The objectives of this study were to identify the spectrum of AH causes, to characterise the frequency of AH due to HIT and determine the natural history of HIT-associated AH. All patients with incident adrenal haemorrhage from January 2002 through June 2012 seen at the Mayo Clinic were identified. Over this time frame, there were a total of 115 patients with AH of which 11 cases (10%; mean age 67 ± 8 years; 73% female) were associated with HIT. Of these, all but one occurred in the postoperative setting and involved both adrenal glands (89%) with acute adrenal insufficiency at the time of diagnosis. Cases were found incidentally during an evaluation for fever, shock, abdominal pain or mental status changes. All HIT patients experienced venous thrombosis at other locations including deep venous thromboses (n=14), pulmonary emboli (n= 4) and arterial thrombosis (n=2). Four patients undergoing total knee arthroplasty had "spontaneous HIT" with AH in the absence of identifiable heparin exposure. Other causes of AH included trauma (29%), sepsis (15%), antiphospholipid antibody syndrome (10%), and metastatic disease (12%). In conclusion, AH is an important but seldom recognised presumed thrombotic complication of HIT, which usually occurs in the postoperative period, especially after orthopaedic procedures. This syndrome can occur in the apparent absence of heparin exposure, especially following major joint replacement surgery.

Topics: Adrenal Gland Diseases; Adrenal Insufficiency; Aged; Aged, 80 and over; Anticoagulants; Disease-Free Survival; Female; Heparin; Humans; Incidence; Male; Middle Aged; Minnesota; Postoperative Hemorrhage; Risk Factors; Thrombocytopenia; Time Factors; Treatment Outcome; Venous Thromboembolism; Warfarin

Bilateral adrenal hemorrhage resulting in acute adrenal insufficiency is a rare complication of anticoagulant therapy. We present the case of a patient who came to the Emergency Department with unsuspected adrenal insufficiency, followed by a second visit within 1 month with shock, to demonstrate the importance of early detection and treatment.

Topics: Adrenal Gland Diseases; Adrenal Insufficiency; Aged; Anticoagulants; Hemorrhage; Humans; Hypotension; Kidney; Male; Warfarin

Heparin-induced thrombocytopenia (HIT) is a well-recognized syndrome associated with thrombosis and multiple potential clinical sequelae. We report a case of bilateral adrenal hemorrhage, a known but rare complication of heparin-induced thrombocytopenia complicating a routine coronary artery bypass surgery. Thrombocytopenia, abdominal pain, and signs of adrenal insufficiency in the context of heparin treatment should raise suspicion of this unusual complication.

Topics: Adrenal Gland Diseases; Anticoagulants; Coronary Artery Bypass; Hemorrhage; Heparin; Humans; Male; Middle Aged; Thrombocytopenia; Warfarin

After joint arthroplasty, the risk of deep vein thrombosis and pulmonary embolism increases exponentially. Inadequate anticoagulation prophylaxis may not sufficiently reduce the risk of thrombosis, whereas excessive anticoagulation therapy may predispose the patient to a bleed. Bilateral adrenal hemorrhage is a relatively rare but potentially catastrophic life-threatening event. An 82-yr-old woman is described who was rehospitalized from a subacute rehabilitation facility complaining of epigastric pain radiating into her flank. Eight days previously, she had undergone an uncomplicated bilateral total knee arthroplasty and was subsequently administered subcutaneous heparin and warfarin. An abdominal computed tomographic scan subsequently demonstrated bilateral small adrenal hemorrhages. Acute adrenal insufficiency (Addison's disease) caused by hemorrhage within the adrenal cortices, although still uncommon, can be expected to increase as anticoagulation prophylaxis after joint arthroplasty becomes routine.

Topics: Adrenal Gland Diseases; Aged; Aged, 80 and over; Anti-Inflammatory Agents; Anticoagulants; Arthroplasty, Replacement, Knee; Female; Hemorrhage; Heparin; Humans; Hydrocortisone; Postoperative Complications; Tomography, X-Ray Computed; Treatment Outcome; Warfarin

Topics: Adrenal Gland Diseases; Adrenal Insufficiency; Aldosterone; Antibodies, Anticardiolipin; Antiphospholipid Syndrome; Autoantibodies; Female; Glucocorticoids; Hemorrhage; Humans; Hydrocortisone; Middle Aged; Partial Thromboplastin Time; Tomography, X-Ray Computed; Warfarin

Topics: Adrenal Gland Diseases; Adrenocorticotropic Hormone; Combined Modality Therapy; Female; Hemorrhage; Humans; Hydrocortisone; Hypotension; Leiomyosarcoma; Middle Aged; Thrombophlebitis; Tomography, X-Ray Computed; Uterine Neoplasms; Vena Cava Filters; Warfarin

We describe a patient with a 3-year history of recurrent deep vein thromboses (DVT) of the lower limbs, who developed adrenal insufficiency following withdrawal of warfarin therapy. Multiple splinter haemorrhages of the nail beds were evident, simultaneous with the development of adrenal infarction in the absence of infective endocarditis. CT scans of the adrenal glands were consistent with bilateral adrenal infarctions. The patient had persistently high titres of IgG anticardiolipin antibodies (aCL) over the previous 4 years in the absence of antinuclear antibodies (ANA), antibodies to double stranded deoxyribonucleic acid (dsDNA) or extractable nuclear antigens (ENA). Thrombocytopenia and an intermittently positive Coombs' test had been noted. Previous episodes of DVT were associated with inadequate warfarin control and a period of warfarin resistance. He conforms to a diagnosis of a 'primary' antiphospholipid syndrome.

Topics: Adrenal Gland Diseases; Adult; Antiphospholipid Syndrome; Gastrointestinal Hemorrhage; Hemorrhage; Humans; Infarction; Male; Nail Diseases; Rectum; Thrombophlebitis; Tomography, X-Ray Computed; Warfarin

A family is described in which venous thromboembolic disease is associated with reduced plasma protein C activity and normal levels of protein C antigen. Immunoelectrophoretic analysis of protein C antigen gave an abnormal pattern in all affected members, suggesting that the disorder is related to the presence of a structurally and functionally abnormal form of protein C. The propositus developed simultaneous warfarin-induced skin necrosis and bilateral adrenal hemorrhage. This is the first reported instance of warfarin-induced skin necrosis associated with a dysfunctional protein C molecule and the first reported instance of simultaneous warfarin-induced skin necrosis and bilateral adrenal hemorrhage.

Topics: Adrenal Gland Diseases; Hemorrhage; Humans; Immunoelectrophoresis, Two-Dimensional; Male; Middle Aged; Necrosis; Protein C; Protein C Deficiency; Protein Deficiency; Skin; Warfarin

Pulmonary embolism remains a frequent and often fatal disorder. For the majority of patients, anticoagulation with heparin followed by warfarin represents the primary mode of treatment. Thrombolytic therapy is recommended for the patient with massive pulmonary embolism that has produced hypotension. Embolectomy is reserved for the patient with post embolic systemic hypotension who has an absolute contraindication to thrombolysis or who deteriorates despite thrombolytic therapy. Following successful embolectomy the surgeon must treat the complications of the surgery and prevent recurrence. Complications include cerebral infarction, pulmonary infarction and endobronchial hemorrhage, right ventricular failure, local or systemic bleeding and venous stasis. A case of successful pulmonary embolectomy with a complicated postoperative course is presented and the pathophysiology and treatment of the complications are discussed.

Topics: Adrenal Gland Diseases; Chest Pain; Dyspnea; Female; Heparin; Humans; Hypotension; Middle Aged; Pain; Postoperative Complications; Pulmonary Embolism; Syncope; Warfarin

Topics: Adrenal Cortex Hormones; Adrenal Gland Diseases; Adrenal Insufficiency; Adrenocorticotropic Hormone; Adult; Aged; Hemorrhage; Heparin; Humans; Hydrocortisone; Male; Middle Aged; Pulmonary Embolism; Warfarin

Topics: Acute Disease; Adrenal Gland Diseases; Adrenal Insufficiency; Aged; Anticoagulants; Hemorrhage; Heparin; Humans; Hydrocortisone; Male; Middle Aged; Thrombophlebitis; Warfarin

Topics: Adrenal Gland Diseases; Aged; Electrocardiography; Heart Failure; Hemorrhage; Heparin; Humans; Injections, Intravenous; Injections, Subcutaneous; Male; Middle Aged; Organ Size; Pulmonary Edema; Thrombophlebitis; Warfarin