warfarin and Adrenal-Insufficiency

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

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

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 Insufficiency; Adult; Antiphospholipid Syndrome; Humans; Hydrocortisone; Male; Thrombophlebitis; Warfarin

Topics: Acute Disease; Adrenal Cortex Diseases; Adrenal Insufficiency; Cortisone; Female; Heparin; Humans; Middle Aged; 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