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Ornaghi S, Fernicola F, Marelli E, Perotti M, Di Gennaro F, Cameroni I, Mariani EM, Pincelli AI, Colciago E, Cetin I, Vergani P. Acute spontaneous non-hemorrhagic adrenal infarction in pregnancy: case-report and literature review. Gynecol Endocrinol 2023; 39:2234492. [PMID: 37486308 DOI: 10.1080/09513590.2023.2234492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 07/05/2023] [Indexed: 07/25/2023] Open
Abstract
Unilateral non-hemorrhagic adrenal infarction (NHAI) is a very uncommon cause of acute abdomen in pregnancy. Diagnosis is highly challenging due to its rarity, heterogeneity of clinical presentation, and inconclusiveness of the initial workup. Timely recognition is pivotal to ensuring optimal outcomes. Here we describe a case of spontaneous unilateral NHAI diagnosed in a singleton pregnant woman at 32 weeks' gestation at our centre and provide the findings of an extensive literature review on the topic. We identified 22 articles describing 31 NHAI cases in 30 obstetric patients: NHAI occurs more frequently on the right side and in the third trimester, and diagnosis is formulated more than 24 h after clinical presentation in 50% of cases; second-level imaging is always necessary to reach a definitive diagnosis and start appropriate treatment. A high degree of clinical suspicion is needed to promptly recognize NHAI in pregnancy, thus allowing appropriate multidisciplinary management and timely treatment initiation. Promotion of knowledge and awareness of NHAI as a potential cause of acute abdomen in pregnancy is mandatory to improve clinical practice and, ultimately, perinatal outcomes.
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Affiliation(s)
- Sara Ornaghi
- Department of Obstetrics, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
| | - Federica Fernicola
- Department of Obstetrics, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
| | - Elisabetta Marelli
- Department of Clinical and Biological Sciences, University of Milan, Milan, Italy
- Department of Woman, Mother, and Neonate, Buzzi Children's Hospital-ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Mario Perotti
- Department of Internal Medicine, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | | | - Irene Cameroni
- Department of Obstetrics, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Eloisa M Mariani
- Department of Obstetrics, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Angela I Pincelli
- Department of Internal Medicine, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | | | - Irene Cetin
- Department of Clinical and Biological Sciences, University of Milan, Milan, Italy
- Department of Woman, Mother, and Neonate, Buzzi Children's Hospital-ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Patrizia Vergani
- Department of Obstetrics, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
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2
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Guyon M, Degez M, Artifoni M, Goronflot T, Misbert E, Dochez V, Winer N. Adrenal Gland Necrosis in Pregnancy: How to Manage? Case Series at Nantes University Hospital and Literature Review. J Clin Med 2023; 12:6036. [PMID: 37762978 PMCID: PMC10531684 DOI: 10.3390/jcm12186036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 09/10/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
Adrenal necrosis is a rare but serious cause of abdominal pain of thrombotic origin during pregnancy. There is often a delay in diagnosis and treatment. The objective was to specify the clinical and paraclinical signs suggestive of adrenal necrosis, making it possible to improve the delay in diagnostic. The secondary objective was to establish a multidisciplinary protocol regarding management. This is a case report of pregnant women with a radiological diagnosis of adrenal gland necrosis. In parallel, we carried out a systematic review in the same period. We studied these patients' clinical, biological and radiological data. We included eight patients with a computed tomography scan diagnosis of adrenal necrosis and fifteen articles in the literature describing twenty-four cases. All the patients presented with the same symptoms. The treatment was based on curative anticoagulation. The diagnosis of adrenal gland necrosis is worth suggesting in view of the array of sudden morphine-resistant abdominal pain associated with a biological inflammatory syndrome. The diagnosis is based on the computed tomography scan. Three to six months of curative anticoagulation is recommended as well as a thrombophilia and endocrinological assessment to rule out adrenal insufficiency.
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Affiliation(s)
- Mathilde Guyon
- Department of Gynecology-Obstetrics, Nantes University Hospital, 44000 Nantes, France (V.D.); (N.W.)
| | - Manon Degez
- Department of Gynecology-Obstetrics, Nantes University Hospital, 44000 Nantes, France (V.D.); (N.W.)
| | - Mathieu Artifoni
- Department of Internal Medicine, Nantes University Hospital, 44000 Nantes, France;
| | - Thomas Goronflot
- Data Clinic, National Institute for Health and Medical Research, Nantes University Hospital, 44000 Nantes, France;
| | - Emilie Misbert
- Department of Gynecology-Obstetrics, Nantes University Hospital, 44000 Nantes, France (V.D.); (N.W.)
| | - Vincent Dochez
- Department of Gynecology-Obstetrics, Nantes University Hospital, 44000 Nantes, France (V.D.); (N.W.)
| | - Norbert Winer
- Department of Gynecology-Obstetrics, Nantes University Hospital, 44000 Nantes, France (V.D.); (N.W.)
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3
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Tschuertz N, Kupczyk P, Poetzsch B, Gembruch U, Merz WM. Unilateral Non-Hemorrhagic Adrenal Infarction in Pregnancy: Case Series and Literature Review. J Clin Med 2023; 12:4855. [PMID: 37510974 PMCID: PMC10381111 DOI: 10.3390/jcm12144855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 07/14/2023] [Accepted: 07/19/2023] [Indexed: 07/30/2023] Open
Abstract
To summarize the evidence on non-hemorrhagic adrenal infarction (NHAI) and identify questions arising in diagnosis and management, cases in the PubMed database were merged with our case series. A total of 92 publications were retrieved, 15 of which reported on NHAI during pregnancy. Including the four in our case series, 24 cases have been described so far. Severe, unremitting pain requiring opioid analgesia was the leading symptom, often combined with nausea and vomiting. Laboratory results were non-contributory in most cases. Diagnosis was established via MRI in nine cases (37.5%) and via CT in six (25%); nine patients (37.5%) underwent both investigations. Location was predominantly on the right side (n = 16, 66.7%). In addition to analgesia, anticoagulation with heparin was commenced in 18 cases (75%). When thrombophilia screening was performed, major thrombogenic polymorphisms were detected in six cases (33.3%). One woman developed signs of adrenal insufficiency. The reported perinatal outcome was unremarkable. Unilateral NHAI has emerged as a rare but important cause of severe abdominal pain in pregnancy. The threshold to perform an MRI in pregnant women with characteristic clinical findings should be low. To prevent fetal radiation exposure, diagnostic imaging via CT should be avoided. In addition to symptomatic treatment with opioid analgesia, initiation of anticoagulant treatment should be strongly considered.
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Affiliation(s)
- Nikolai Tschuertz
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Patrick Kupczyk
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, 53127 Bonn, Germany
| | - Bernd Poetzsch
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Ulrich Gembruch
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Waltraut M Merz
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, 53127 Bonn, Germany
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4
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Hoshino Y, Manaka K, Sato J, Asatsuma Y, Horikoshi H, Takeuchi M, Ito N, Fujita M, Yasunaga M, Matsuda K, Honda A, Maki H, Masamoto Y, Kurokawa M, Nangaku M, Makita N. Recurrent bilateral adrenal infarction with myelodysplastic/myeloproliferative neoplasm-unclassifiable (MDS/MPN-U): a case report. BMC Endocr Disord 2023; 23:128. [PMID: 37277771 DOI: 10.1186/s12902-023-01384-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 05/30/2023] [Indexed: 06/07/2023] Open
Abstract
BACKGROUND Bilateral adrenal infarction is rare and only a small number of cases have been reported so far. Adrenal infarction is usually caused by thrombophilia or a hypercoagulable state, such as antiphospholipid antibody syndrome, pregnancy, and coronavirus disease 2019. However, adrenal infarction with myelodysplastic/myeloproliferative neoplasm (MDS/MPN) has not been reported. CASE PRESENTATION An 81-year-old man with a sudden severe bilateral backache presented to our hospital. Contrast-enhanced computed tomography (CT) led to the diagnosis of bilateral adrenal infarction. Previously reported causes of adrenal infarction were all excluded and a diagnosis of MDS/MPN-unclassifiable (MDS/MPN-U) was reached, which was considered to be attributed to adrenal infarction. He developed a relapse of bilateral adrenal infarction, and aspirin administration was initiated. Partial primary adrenal insufficiency was suspected as the serum adrenocorticotropic hormone level was persistently high after the second bilateral adrenal infarction. CONCLUSION This is the first case of bilateral adrenal infarction with MDS/MPN-U encountered. MDS/MPN has the clinical characteristics of MPN. It is reasonable to assume that MDS/MPN-U may have influenced bilateral adrenal infarction development, considering the absence of thrombosis history and a current comorbid hypercoagulable disease. This is also the first case of recurrent bilateral adrenal infarction. It is important to carefully investigate the underlying cause of adrenal infarction once adrenal infarction is diagnosed, as well as to assess adrenocortical function.
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Affiliation(s)
- Yoshitomo Hoshino
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Katsunori Manaka
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Junichiro Sato
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Yui Asatsuma
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Hirofumi Horikoshi
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Maki Takeuchi
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Nobuaki Ito
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Megumi Fujita
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Megumi Yasunaga
- Department of Hematology and Oncology, The University of Tokyo Hospital, Tokyo, Japan
| | - Kensuke Matsuda
- Department of Hematology and Oncology, The University of Tokyo Hospital, Tokyo, Japan
| | - Akira Honda
- Department of Hematology and Oncology, The University of Tokyo Hospital, Tokyo, Japan
| | - Hiroaki Maki
- Department of Hematology and Oncology, The University of Tokyo Hospital, Tokyo, Japan
| | - Yosuke Masamoto
- Department of Hematology and Oncology, The University of Tokyo Hospital, Tokyo, Japan
| | - Mineo Kurokawa
- Department of Hematology and Oncology, The University of Tokyo Hospital, Tokyo, Japan
- Department of Cell Therapy and Transplantation Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Noriko Makita
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan.
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5
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Shah N, Deshmukh H, Akbar MJ, Saeed Y, Akbar S, Malik S, Allan B. Unilateral adrenal infarction in pregnancy with associated acute hypoadrenalism and subsequent spontaneous biochemical and radiological resolution. Clin Case Rep 2022; 10:e05442. [PMID: 35169476 PMCID: PMC8831941 DOI: 10.1002/ccr3.5442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 01/19/2022] [Accepted: 01/31/2022] [Indexed: 11/21/2022] Open
Abstract
Adrenal infarction is a rare cause of abdominal pain during pregnancy, and if missed, it can result in devastating clinical consequences for the mother and the child. The authors report a case of a young female who presented with severe abdominal pain and nausea. The biochemistry showed raised inflammatory markers and significant lactic acidosis. As the cause of the symptoms was not clear and the patient continued to deteriorate, a contrast-enhanced CT abdomen and pelvis was done which was suggestive of an acute left adrenal infarction. Subsequently, the patient was confirmed to have biochemical hypoadrenalism and required replacement doses of hydrocortisone until recovery of the adrenal glucocorticoid reserve and anticoagulation for the duration of pregnancy. We discuss the workup including diagnostic imaging, follow-up, and considerations for future pregnancies in this case.
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Affiliation(s)
- Najeeb Shah
- Hull University Teaching Hospitals NHS TrustHull Royal InfirmaryHullUK
- University of HullHullUK
| | - Harshal Deshmukh
- Hull University Teaching Hospitals NHS TrustHull Royal InfirmaryHullUK
- University of HullHullUK
| | | | - Yamna Saeed
- Hull University Teaching Hospitals NHS TrustHull Royal InfirmaryHullUK
| | - Shahzad Akbar
- York and Scarborough Teaching Hospitals NHS Foundation TrustYorkUK
| | - Shah Malik
- Hull University Teaching Hospitals NHS TrustHull Royal InfirmaryHullUK
| | - Belinda Allan
- Hull University Teaching Hospitals NHS TrustHull Royal InfirmaryHullUK
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Mathew R, Ali A, Sanders K, Flint A, Lamsal S, DeReus H, Cueno M, Jacob R. Adrenal Infarction in Pregnancy Secondary to Elevated Plasma Factor VIII Activity. Cureus 2021; 13:e19491. [PMID: 34912632 PMCID: PMC8664400 DOI: 10.7759/cureus.19491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2021] [Indexed: 11/05/2022] Open
Abstract
Unilateral adrenal infarction is a rare cause of acute abdomen in pregnancy (AAP). Its presentation is non-specific and requires a high index of suspicion with a low threshold to obtain radiographic imaging for diagnosis. Evaluating AAP is challenging as diagnostic radiographic imaging is often limited in relation to radiation exposure to the developing fetus. We describe a case of a 24-year-old pregnant female who presented with severe acute abdominal pain. The patient’s pain was refractory to intravenous analgesics and ultrasonography was inconclusive. Computed tomography (CT) scan was not obtained due to the risk of radiation exposure to the developing fetus. Due to the persistence of pain and suspicions for other serious etiologies, magnetic resonance imaging (MRI) was completed and the patient was diagnosed with acute unilateral adrenal infarction. In this case report, unilateral adrenal infarction was likely secondary to elevated plasma factor VIII levels. Even with the physiological elevation of factor VIII levels during pregnancy, levels greater than 150 IU/dL confer greater than five-fold increased risk of venous thrombosis. Once hemorrhage is excluded, patients should be started on therapeutic anticoagulation to prevent progression of adrenal infarct or infarction of the contralateral adrenal gland. Prompt recognition and treatment of acute adrenal infarction during pregnancy are of paramount importance to prevent adverse outcomes for both the mother and fetus.
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Affiliation(s)
- Reshmi Mathew
- Internal Medicine, University of Florida College of Medicine, Jacksonville, USA
| | - Aleem Ali
- General Internal Medicine, University of Florida College of Medicine, Jacksonville, USA
| | - Kimberly Sanders
- General Internal Medicine, University of Florida College of Medicine, Jacksonville, USA
| | - Andrew Flint
- General Internal Medicine, University of Florida College of Medicine, Jacksonville, USA
| | - Sanjay Lamsal
- Radiology, University of Florida College of Medicine, Jacksonville, USA
| | - Heather DeReus
- General Internal Medicine, University of Florida College of Medicine, Jacksonville, USA
| | - Micaela Cueno
- General Internal Medicine, University of Florida College of Medicine, Jacksonville, USA
| | - Rafik Jacob
- Internal Medicine, University of Florida College of Medicine, Jacksonville, USA
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7
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Non-Hemorrhagic Adrenal Infarction during Pregnancy: The Diagnostic Imaging Keys. Tomography 2021; 7:533-544. [PMID: 34698296 PMCID: PMC8544682 DOI: 10.3390/tomography7040046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 09/20/2021] [Accepted: 10/02/2021] [Indexed: 11/17/2022] Open
Abstract
Background: non-hemorrhagic adrenal infarction (NHAI) is a rare cause of acute abdominal/flank pain during pregnancy; in order to ensure prompt and appropriate treatment, this diagnosis should not be overlooked. This case series highlights pertinent imaging findings, including ultrasounds (USs), computed tomography (CT), and magnetic resonance imaging (MRI) of recent NHAI cases. Methods: we compiled all consecutive NHAI cases from two university hospitals over a two-year period and checked the relevant clinical, laboratory, and imaging findings. Relevant articles on NHAI published from January 2010 to March 2021 were analyzed. Results: six cases were found in our database. CT-scans typically showed enlarged, hypodense, and non-enhanced adrenal glands. Unenhanced MRIs allowed for diagnoses and showed enlarged adrenal glands in the signal hyperintensity on T2 and diffusion-weighted imaging, without any signal hyperintensity on T1. In two of our six cases, USs showed swollen adrenal glands with fluid collection. Conclusion: NHAI and its differential diagnosis-in cases of acute pain during pregnancy-highlight the crucial roles of integrated radiological examination and cooperation between obstetricians and radiologists, both of whom should consider the location of the pain, the accessibility and tolerance of MRI, and the radiation exposure of CT. Despite its supposed poor sensitivity, an US performed because the patient reports pain should also be used to examine the adrenal gland regions. Non-enhanced MRI is clearly of value and access to it in emergencies is important to avoid radiation exposure.
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8
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Warda F, Soule E, Gopireddy D, Gandhi GY. Acute Unilateral Nonhemorrhagic Adrenal Infarction in Pregnancy. AACE Clin Case Rep 2021; 7:228-229. [PMID: 34095495 PMCID: PMC8165107 DOI: 10.1016/j.aace.2020.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Firas Warda
- Division of Endocrinology, University of Florida College of Medicine - Jacksonville, Florida
- Department of Medicine, University of Florida College of Medicine - Jacksonville, Florida
| | - Erik Soule
- Department of Radiology, University of Florida College of Medicine - Jacksonville, Florida
| | - Dheeraj Gopireddy
- Department of Radiology, University of Florida College of Medicine - Jacksonville, Florida
| | - Gunjan Y. Gandhi
- Division of Endocrinology, University of Florida College of Medicine - Jacksonville, Florida
- Department of Medicine, University of Florida College of Medicine - Jacksonville, Florida
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9
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Sidibe S, Perazzini C, Cassagnes L, Boyer L, Magnin B. The role of computed tomography in adrenal gland infarction diagnosis during pregnancy: Two case reports. JOURNAL DE MÉDECINE VASCULAIRE 2020; 46:28-31. [PMID: 33546818 DOI: 10.1016/j.jdmv.2020.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 11/21/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Seydou Sidibe
- Radiology Department, University Hospital Gabriel Montpied, 58, rue Montalembert, 63000 Clermont-Ferrand, France
| | - Chiara Perazzini
- Radiology Department, University Hospital Gabriel Montpied, 58, rue Montalembert, 63000 Clermont-Ferrand, France.
| | - Lucie Cassagnes
- Radiology Department, University Hospital Gabriel Montpied, 58, rue Montalembert, 63000 Clermont-Ferrand, France
| | - Louis Boyer
- Radiology Department, University Hospital Gabriel Montpied, 58, rue Montalembert, 63000 Clermont-Ferrand, France
| | - Benoit Magnin
- Radiology Department, University Hospital Estaing, Clermont-Ferrand, France
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10
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Chasseloup F, Bourcigaux N, Christin-Maitre S. Unilateral nonhaemorrhagic adrenal infarction as a cause of abdominal pain during pregnancy. Gynecol Endocrinol 2019; 35:941-944. [PMID: 31155980 DOI: 10.1080/09513590.2019.1622088] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Adrenal infarction is usually associated with bilateral adrenal hemorrhage in the setting of antiphospholipid syndrome or hemodynamic variation. Few cases of unilateral nonhemorrhagic adrenal infarction (NHAI) have been described in the literature. Here, we report a case occurring during pregnancy. A 30-year-old woman presented at 32 weeks of gestation with sudden-onset right abdominal pain and contractions. Unilateral adrenal infarction was diagnosed following computed tomography (CT). It showed an enlarged right adrenal, without hyperenhancement. Because of persisting contractions, despite medical care, she delivered a healthy, albeit premature, girl. Abdominal pain decreased right after delivery. Three month later, CT imaging showed atrophy of the right adrenal and a normal left adrenal. The patient's adrenal hormonal function was normal. Accurate diagnosis of NHAI remains difficult as its clinical presentation is not specific. It can only be performed with adrenal imaging. Magnetic resonance imaging shows diffuse enlargement of one or both adrenals and an edema on T2-weighted images. Anticoagulation therapy may be discussed. Patients should be evaluated between 3 and 6 months after the event to assess adrenal size and function. In summary, NHAI during pregnancy is probably underdiagnosed and obstetricians should be aware of this or diagnostic difficulty.
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Affiliation(s)
- F Chasseloup
- Department of Endocrinology, University Hospital Saint-Antoine , Paris , France
| | - N Bourcigaux
- Department of Endocrinology, University Hospital Saint-Antoine , Paris , France
| | - S Christin-Maitre
- Department of Endocrinology, University Hospital Saint-Antoine , Paris , France
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11
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Peng Y, Xie Q, Wang H, Lin Z, Zhang F, Zhou X, Guan J. The hollow adrenal gland sign: a newly described enhancing pattern of the adrenal gland on dual-phase contrast-enhanced CT for predicting the prognosis of patients with septic shock. Eur Radiol 2019; 29:5378-5385. [PMID: 30937586 DOI: 10.1007/s00330-019-06172-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 03/03/2019] [Accepted: 03/15/2019] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To investigate the incidence, CT appearance, and implication for prognosis of the hollow adrenal gland sign (HAGS). METHODS A total of 194 patients with septic shock and 24 patients with hemorrhagic shock (as control group) were retrospectively included in this study and the patients with septic shock were further divided into four subgroups (digestive tract diseases, DTD, n = 49; biliary and pancreatic diseases, BPD, n = 41; postsurgical infection, PI, n = 64; and other diseases, OD, n = 40). All patients underwent a dual-phase contrast-enhanced CT within 1 week after diagnosis. CT findings and clinical records were reviewed. If in the arterial phase the central zone of adrenal gland showed temporally much lower attenuation than the peripheral zone, it was defined as HAGS positive. The incidence of the HAGS in patients with septic shock and hemorrhagic shock, the demographic features, and mortality between HAGS-positive and HAGS-negative patients in each group were respectively compared. RESULTS The incidence of the HAGS in the septic shock group was nearly 30%, while it was 0 in the hemorrhagic shock group. There was no significant difference in age or gender between HAGS-positive and HAGS-negative patients in all groups, while the mortality of HAGS-positive patients was significantly higher than that of HAGS-negative patients in each group (p < 0.05). The concordance correlation coefficient value showed excellent reproducibility of the two observers (κ = 0.977). CONCLUSION The HAGS is specific and common on dual-phase contrast-enhanced CT in patients with septic shock and predicts a poor prognosis. KEY POINTS • The hollow adrenal gland sign (HAGS) newly described in this study is a special enhancing pattern of adrenal gland on dual-phase contrast-enhanced CT in patients with septic shock. • The HAGS is characterized by the much lower-attenuated central zone of the adrenal gland in arterial phase and it showed excellent reproducibility between different observers. • The HAGS is specific and common on dual-phase contrast-enhanced CT in patients with septic shock and predicts a poor prognosis.
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Affiliation(s)
- Yang Peng
- Department of Radiology, The First Affiliated Hospital of Sun Yat-Sen University, No.58 Zhongshanerlu Road, Guangzhou, Guangdong, People's Republic of China
| | - Qiuxia Xie
- Department of Radiology, The Eighth Affiliated Hospital of Sun Yat-Sen University, No.3025 Shennanzhonglu Road, Shenzhen, Guangdong, People's Republic of China
| | - Huanjun Wang
- Department of Radiology, The First Affiliated Hospital of Sun Yat-Sen University, No.58 Zhongshanerlu Road, Guangzhou, Guangdong, People's Republic of China
| | - Zhi Lin
- Department of Radiology, The First Affiliated Hospital of Sun Yat-Sen University, No.58 Zhongshanerlu Road, Guangzhou, Guangdong, People's Republic of China
| | - Fan Zhang
- Department of Radiology, The First Affiliated Hospital of Sun Yat-Sen University, No.58 Zhongshanerlu Road, Guangzhou, Guangdong, People's Republic of China
| | - Xuhui Zhou
- Department of Radiology, The Eighth Affiliated Hospital of Sun Yat-Sen University, No.3025 Shennanzhonglu Road, Shenzhen, Guangdong, People's Republic of China.
| | - Jian Guan
- Department of Radiology, The First Affiliated Hospital of Sun Yat-Sen University, No.58 Zhongshanerlu Road, Guangzhou, Guangdong, People's Republic of China.
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12
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Agarwal KA, Soe MH. Cryptogenic adrenal infarction: a rare case of unilateral adrenal infarction in a pregnant woman. BMJ Case Rep 2019; 12:12/3/e228795. [PMID: 30917968 DOI: 10.1136/bcr-2018-228795] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Adrenal infarction is a rare event, especially in pregnancy. The diagnosis is challenging because patients present with acute abdomen and initial workup are usually unrevealing. We present a case of unilateral adrenal infarction in a pregnant young woman without any other causes of thrombophilia, who presented with acute abdominal pain and an unremarkable initial workup. MRI and contrast-enhanced CT scan revealed a non-haemorrhagic infarct of the right adrenal gland. Our case highlights the importance of considering this rare diagnosis in the differential for a pregnant woman with acute abdomen without any obvious surgical cause.
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Affiliation(s)
- Krishna Adit Agarwal
- Baystate Medical Center, University of Massachusetts, Springfield, Massachusetts, USA
| | - Myat Han Soe
- Baystate Medical Center, University of Massachusetts, Springfield, Massachusetts, USA
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Fujiwara Y, Ito K, Takamura A, Nagata K. The first case of thrombocytopenia, anasarca, fever, renal impairment or reticulin fibrosis, and organomegaly (TAFRO) syndrome with unilateral adrenal necrosis: a case report. J Med Case Rep 2018; 12:295. [PMID: 30293532 PMCID: PMC6174561 DOI: 10.1186/s13256-018-1814-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 08/23/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND TAFRO syndrome, which was first reported in 2010 in Japan, is a relatively rare disease characterized by thrombocytopenia, anasarca, fever, renal impairment, reticulin fibrosis, and organomegaly. Although this disease is considered similar to multicentric Castleman disease, some of the clinical features, such as thrombocytopenia, are different from typical cases of multicentric Castleman disease. In addition, the etiology of TAFRO syndrome remains unknown and controversial. There have only been a few cases of TAFRO syndrome complicated with adrenal gland lesions, and all of them have had hemorrhagic involvement. CASE PRESENTATION This report describes the case of a 46-year-old Asian man who presented with fever, epigastric pain, and back pain for 1 month. A computed tomographic scan revealed ascites, mild lymphadenopathy, and left adrenal necrosis without hemorrhage. A blood test showed thrombocytopenia, anemia, and elevated C-reactive protein, alkaline phosphatase, and creatinine levels. Based on the edema, severe thrombocytopenia, fever, reticulin myelofibrosis shown by bone marrow biopsy, mild lymphadenopathy, and progressive renal insufficiency, we diagnosed this patient as having TAFRO syndrome. He was successfully treated by immediate administration of glucocorticoids and tocilizumab. CONCLUSIONS There have been no previous reports of a case of TAFRO syndrome complicated with adrenal necrosis. Because the biopsy of the left adrenal gland revealed necrosis without any evidence of hemorrhage, we concluded that the unilateral adrenal necrosis in this case was caused by either ischemia from infarction or organomegaly itself under severe hypercytokinemia. This unusual clinical course is useful for further analysis of the etiology of TAFRO syndrome.
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Affiliation(s)
- Yu Fujiwara
- Department of Internal Medicine, Musashino Red Cross Hospital, 1-26-1, Kyonancho, Musashino-shi, Tokyo, 1808610 Japan
| | - Kanae Ito
- Department of Rheumatology and Collagen Disease, Musashino Red Cross Hospital, Tokyo, Japan
| | - Akito Takamura
- Department of Rheumatology and Collagen Disease, Musashino Red Cross Hospital, Tokyo, Japan
| | - Kaoru Nagata
- Department of General Internal Medicine, Musashino Red Cross Hospital, Tokyo, Japan
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Cunningham TK, Maydanovych S, Draper H, Antoniades G, Allen J. Adrenal infarction in the immediate postnatal period†. J OBSTET GYNAECOL 2018; 39:410-411. [PMID: 30286671 DOI: 10.1080/01443615.2018.1472557] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
| | - Slavyana Maydanovych
- a The Women and Children's Hospital, Hull Royal Infirmary , Hull , United Kingdom
| | - Hannah Draper
- a The Women and Children's Hospital, Hull Royal Infirmary , Hull , United Kingdom
| | | | - Jane Allen
- a The Women and Children's Hospital, Hull Royal Infirmary , Hull , United Kingdom
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Aljenaee KY, Ali SA, Cheah SK, Alroomi MJ. Unilateral adrenal infarction in pregnancy secondary to elevated factor VIII. Saudi Med J 2018; 38:654-656. [PMID: 28578446 PMCID: PMC5541190 DOI: 10.15537/smj.2017.6.18520] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Adrenal infarction in pregnancy is an extremely rare event. We report a case of a 29-year-old pregnant woman at the twenty-fourth week of gestation that presented with an acute episode of severe localized right upper quadrant pain. Her preliminary blood investigations and abdominal ultrasonography were essentially unremarkable. A diagnosis of right adrenal infarction was subsequently established on the basis of a non-enhanced swollen right adrenal gland on CT scanning of the abdomen with contrast, consistent with the clinical presentation. She was treated with subcutaneous low molecular weight heparin (LMWH) until 2 weeks postpartum. A thrombophilia screen post-partum revealed a significantly elevated factor VIII level and a hypercoagulable state that justified prolonged anticoagulation. This case highlights the importance of a high index of suspicion for adrenal infarction in pregnancy on the clinical grounds of otherwise unexplained acute abdominal pain accompanied by suggestive radiological findings, especially in the presence of thrombophilia.
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Affiliation(s)
- Khaled Y Aljenaee
- Department of Endocrinology, Connolly Hospital,Mater Misericordiae University Hospital, Dublin, Ireland, E-mail.
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Acute Nonhemorrhagic Adrenal Infarction in Pregnancy: 10-Year MRI Incidence and Patient Outcomes at a Single Institution. AJR Am J Roentgenol 2018; 210:785-791. [PMID: 29446684 DOI: 10.2214/ajr.17.18739] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study was to retrospectively investigate the MRI incidence of nonhemorrhagic adrenal infarction in pregnant women undergoing MRI evaluation of acute abdominal or flank pain, assess the MRI features quantitatively, and report patient outcomes. MATERIALS AND METHODS All abdominal MRI examinations of pregnant women with acute pain at one institution from May 2005 to April 2015 were reviewed. The adrenals were evaluated for abnormal morphologic and signal intensity characteristics described in the literature characterizing nonhemorrhagic adrenal infarction and were compared with the contralateral adrenal by paired t tests. The findings were correlated with clinical presentation. Patient demographics and outcomes were gathered from the medical record. RESULTS Findings of nonhemorrhagic adrenal infarction were present in 5 of 379 (1.3%) examinations of four pregnant patients (mean age, 28 years; range, 20.8-33.9 years; mean gestational age, 26 weeks; range, 16-35 weeks). MRI features included lengthening (mean, 39.8 versus 21.2 mm) (p = 0.005) and increased T2 signal intensity (p = 0.001) of the infarcted adrenal with surrounding edema and without T1 signal intensity suggesting hemorrhage. No alternative diagnosis was identified. All patients presented with severe acute abdominal or flank pain on the same side as the MRI findings, tenderness to palpation, and mild leukocytosis. All women delivered healthy infants. CONCLUSION Unilateral nonhemorrhagic adrenal infarction was identified in 1.3% of abdominal MRI examinations performed for pregnant women with acute abdominal or flank pain. Knowledge of the MRI characteristics of this entity is important for recognizing it and may prevent further potentially invasive tests, procedures, or missed diagnoses.
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Ricci ZJ, Oh SK, Stein MW, Kaul B, Flusberg M, Chernyak V, Rozenblit AM, Mazzariol FS. Solid organ abdominal ischemia, part I: clinical features, etiology, imaging findings, and management. Clin Imaging 2016; 40:720-31. [DOI: 10.1016/j.clinimag.2016.02.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 01/26/2016] [Accepted: 02/17/2016] [Indexed: 02/08/2023]
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