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Shoji M, Hyodo T, Nagasawa Y, Nishihara M, Nakamura H, Nakamura Y, Kobayashi H, Abe M, Okada M. A case of bilateral adrenal infarction with preserved adrenal function diagnosed by dual-energy computed tomography. Radiol Case Rep 2024; 19:2879-2885. [PMID: 38706813 PMCID: PMC11066988 DOI: 10.1016/j.radcr.2024.03.065] [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: 01/16/2024] [Revised: 03/09/2024] [Accepted: 03/25/2024] [Indexed: 05/07/2024] Open
Abstract
We report a case wherein adrenal function remained preserved despite bilateral adrenal infarction, as evidenced by dual-energy computed tomography (DECT) iodine density images. The patient was a 37-year-old man with a history of antiphospholipid syndrome concomitant with systemic lupus erythematosus. The patient underwent contrast-enhanced DECT, which revealed bilateral adrenal infarction. Laboratory tests revealed preserved adrenal function. On the iodine density images, the infarcted and noninfarcted areas in the adrenal glands were visually different. The volume of the non-infarcted area was 8.9 mL, which was 41% of the total adrenal volume. DECT may be a useful complementary tool for assessing the preservation of adrenal function.
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Affiliation(s)
- Misaki Shoji
- Department of Radiology, Nihon University School of Medicine, 30-1 Ohyaguchi-kami-cho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Tomoko Hyodo
- Department of Radiology, Nihon University School of Medicine, 30-1 Ohyaguchi-kami-cho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Yosuke Nagasawa
- Division of Hematology and Rheumatology, Department of Internal Medicine, Nihon University School of Medicine, 30-1 Ohyaguchi-kami-cho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Masahiro Nishihara
- Division of Hematology and Rheumatology, Department of Internal Medicine, Nihon University School of Medicine, 30-1 Ohyaguchi-kami-cho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Hideki Nakamura
- Division of Hematology and Rheumatology, Department of Internal Medicine, Nihon University School of Medicine, 30-1 Ohyaguchi-kami-cho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Yoshihiro Nakamura
- Division of Nephrology, Hypertension and Endocrinology, Department of Internal Medicine, Nihon University School of Medicine, 30-1 Ohyaguchi-kami-cho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Hiroki Kobayashi
- Division of Nephrology, Hypertension and Endocrinology, Department of Internal Medicine, Nihon University School of Medicine, 30-1 Ohyaguchi-kami-cho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Masanori Abe
- Division of Nephrology, Hypertension and Endocrinology, Department of Internal Medicine, Nihon University School of Medicine, 30-1 Ohyaguchi-kami-cho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Masahiro Okada
- Department of Radiology, Nihon University School of Medicine, 30-1 Ohyaguchi-kami-cho, Itabashi-ku, Tokyo 173-8610, Japan
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Ilkhanipoor H, Hajiani Ghotbabadi S, Barzegar H, Sedaghat A. Adrenal insufficiency as a rare manifestation of secondary antiphospholipid syndrome: A pediatric case report and review of articles. Clin Case Rep 2023; 11:e7519. [PMID: 37305880 PMCID: PMC10256869 DOI: 10.1002/ccr3.7519] [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: 03/03/2023] [Revised: 03/23/2023] [Accepted: 05/25/2023] [Indexed: 06/13/2023] Open
Abstract
Key Clinical Message Adrenal insufficiency is a rare, important manifestation of secondary antiphospholipid syndrome (APS) in pediatrics. In the presence of hematologic disorders such as thrombosis, we should consider APS. Abstract Adrenal insufficiency can rarely occur in the context of vascular disorders and thrombosis in patients with antiphospholipid syndrome. There are few case reports in pediatrics. Here, we present a pediatric case-the first pediatric case report in Iran-and review articles in this age group.
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Affiliation(s)
- Homa Ilkhanipoor
- Department of Pediatric Endocrinology and Metabolism, School of MedicineShiraz University of Medical SciencesShirazIran
| | | | - Hamide Barzegar
- Neonatal Research CenterShiraz University of Medical SciencesShirazIran
| | - Atefeh Sedaghat
- Pediatric Endocrinology DepartmentShiraz University of Medical SciencesShirazIran
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3
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Zhang J, Li C, Han X, Chen Z, Adhikari BK, Wang Y, Wang Y, Sun J. The digestive system involvement of antiphospholipid syndrome: pathophysiology, clinical characteristics, and treatment strategies. Ann Med 2021; 53:1328-1339. [PMID: 34409894 PMCID: PMC8381908 DOI: 10.1080/07853890.2021.1962964] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 07/25/2021] [Indexed: 02/03/2023] Open
Abstract
Antiphospholipid syndrome (APS) is an autoimmune disease mainly characterised by vascular thrombosis and pregnancy morbidity. APS has broad spectrum of clinical manifestations. The digestive system involvement of antiphospholipid syndrome is a critical but under-recognised condition. Digestive system involvement may be the result of direct (autoimmune-mediated) or indirect (thrombotic) mechanisms. Liver is the most commonly involved organ, followed by intestines, oesophagus, stomach, pancreas and spleen. This review describes possible digestive system manifestations in APS patients, and illustrates the epidemiology and possible pathophysiology of APS. The role of different treatment strategies in the management of digestive system manifestations of APS were also discussed.Key messagesAntiphospholipid syndrome is a multi-organ, multi-system disease and its clinical manifestation spectrum is gradually expanding. Since the first diagnosis of APS, the clinical manifestations of digestive system have been reported successively. This narrative review describes the major digestive system manifestations of APS and illustrates the epidemiology, pathophysiology and the role of therapeutic strategies of these patients.
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Affiliation(s)
- Jin Zhang
- Department of Cardiovascular Center, Jilin University First Hospital, Changchun, China
| | - Cheng Li
- Department of Cardiovascular Center, Jilin University First Hospital, Changchun, China
| | - Xiaorong Han
- Department of Cardiovascular Center, Jilin University First Hospital, Changchun, China
| | - Zhongbo Chen
- Department of Cardiovascular Center, Jilin University First Hospital, Changchun, China
| | - Binay Kumar Adhikari
- Department of Medicine, Nepal Armed Police Force Command and Staff hospital, Kathmandu, Nepal
| | - Yinghui Wang
- Department of Cardiovascular Center, Jilin University First Hospital, Changchun, China
| | - Yonggang Wang
- Department of Cardiovascular Center, Jilin University First Hospital, Changchun, China
| | - Jian Sun
- Department of Cardiovascular Center, Jilin University First Hospital, Changchun, China
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Mlekuš Kozamernik K, Jensterle M, Ambrožič A, Pfeifer M. Adrenal failure and antiphospholipid syndrome. J Int Med Res 2020; 48:300060520903659. [PMID: 32692293 PMCID: PMC7375731 DOI: 10.1177/0300060520903659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We herein report two cases of primary adrenal insufficiency (AI) associated with antiphospholipid syndrome (APS). In both patients, the main finding that led to the diagnosis was hyponatraemia. The major difference between the two cases was the time at which AI evolved during the course of APS. In the first patient, AI developed acutely along with other presenting features of APS. In the second patient, the AI was unmasked during a stressful situation induced by severe inflammation that occurred 7 years after the first APS manifestation and had probably evolved slowly during the previous few years. These cases emphasise the importance of considering AI in patients with either suspected or newly diagnosed APS as well as in patients who have long been known to have APS. The symptoms and signs alerting the clinician to possible AI are general abdominal complaints, fever, hypotension, and hyponatraemia. Conversely, patients with primary AI should be questioned about the signs and symptoms of APS.
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Affiliation(s)
- Katarina Mlekuš Kozamernik
- Department of Endocrinology, Diabetes and Metabolic Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Mojca Jensterle
- Department of Endocrinology, Diabetes and Metabolic Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Aleš Ambrožič
- Department of Rheumatology, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Marija Pfeifer
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
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Alshahrani MA, Bin Saeedan M, Alkhunaizan T, Aljohani IM, Azzumeea FM. Bilateral adrenal abnormalities: imaging review of different entities. Abdom Radiol (NY) 2019; 44:154-179. [PMID: 29938331 DOI: 10.1007/s00261-018-1670-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Bilateral adrenal abnormalities are not infrequently encountered during routine daily radiology practice. The differential diagnoses of bilateral adrenal abnormalities include neoplastic and non-neoplastic entities. The bilateral adrenal tumors include metastasis, lymphoma, neuroblastoma, pheochromocytoma, adenoma, and myelolipoma. Non-neoplastic bilateral adrenal masses include infectious processes and haematomas. There are different diffuse bilateral adrenal changes such as adrenal atrophy, adrenal enlargement, adrenal calcifications, and altered adrenal enhancement. In this pictorial review article, we will discuss the imaging features of these entities with emphasis on their clinical implications.
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Affiliation(s)
- Meshal Ali Alshahrani
- Department of Radiology, King Faisal Specialist Hospital and Research Center, MBC-28, P.O. Box 3354, Riyadh, 11211, Saudi Arabia
| | - Mnahi Bin Saeedan
- Department of Radiology, King Faisal Specialist Hospital and Research Center, MBC-28, P.O. Box 3354, Riyadh, 11211, Saudi Arabia.
| | - Tariq Alkhunaizan
- Department of Radiology, King Faisal Specialist Hospital and Research Center, MBC-28, P.O. Box 3354, Riyadh, 11211, Saudi Arabia
| | - Ibtisam Musallam Aljohani
- Department of Radiology, King Faisal Specialist Hospital and Research Center, MBC-28, P.O. Box 3354, Riyadh, 11211, Saudi Arabia
| | - Fahad Mohammed Azzumeea
- National Guard Health Affairs, King Abdulaziz Medical City, Medical Imaging Department, Riyadh, Saudi Arabia
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6
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Affiliation(s)
- CS Lau
- University Department of Medicine, Queen Mary Hospital, Hong Kong
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7
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Mohammad K, Bhaskar N, Bartter T, Joshi M. A 62-year-old man with hypotension, hyperkalemia, and hyponatremia. Chest 2013; 143:1822-1825. [PMID: 23732595 DOI: 10.1378/chest.12-2576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Khalid Mohammad
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR.
| | - Nutan Bhaskar
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Thaddeus Bartter
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Manish Joshi
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR
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8
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Bhakhri BK, Katewa S, Sharma R, Mahajan S. Primary antiphospholipid antibody syndrome presenting with adrenal insufficiency in a child: Case report and review of literature. Lupus 2011; 20:1203-8. [DOI: 10.1177/0961203310397965] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A 7-year-old boy presented with adrenal insufficiency. He subsequently developed venous thrombosis in the limbs and was diagnosed with primary antiphospholipid syndrome (PAPS) based on clinical and laboratory parameters. Both adrenals were normal on imaging. He required thrombolysis and anticoagulation. The progressive course of PAPS was controlled with methylprednisolone. There are few reports of PAPS in pediatric patients, and associated adrenal involvement is rare. The unusual presentation, course and management of the patient and of four other reported children with adrenal insufficiency heralding manifestation of PAPS are discussed.
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Affiliation(s)
- BK Bhakhri
- All India Institute of Medical Sciences, New Delhi, India
| | - S Katewa
- Dr B L Kapoor Memorial Hospital, Pusa Road, New Delhi, India
| | - R Sharma
- Dr B L Kapoor Memorial Hospital, Pusa Road, New Delhi, India
| | - S Mahajan
- Dr B L Kapoor Memorial Hospital, Pusa Road, New Delhi, India
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10
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DeLoughery TG. Venous Thrombotic Emergencies. Hematol Oncol Clin North Am 2010; 24:487-500. [DOI: 10.1016/j.hoc.2010.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Bazzi L, Taher AT, Musallam KM, Saleh Z, Masrouha KZ, Uthman I. Thrombotic renal and adrenal manifestations of primary antiphospholipid syndrome. Rheumatol Int 2009; 30:993-4. [PMID: 19701636 DOI: 10.1007/s00296-009-1105-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2009] [Accepted: 08/07/2009] [Indexed: 12/01/2022]
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Abstract
Thrombosis is a common complication of cancer, occurring in up to 15% of patients. This article reviews the diagnosis and management of the most common cancer-related thrombotic problem; deep venous thrombosis, pulmonary embolism, and catheterrelated thrombosis. Rarer entities, such as cerebral vein thrombosis and Budd-Chiari syndrome, are also reviewed.
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Affiliation(s)
- Thomas G DeLoughery
- Division of Hematology and Medical Oncology, Department of Medicine, Oregon Health & Science University, L586, Portland, OR 97201-3098, USA.
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13
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Abstract
Although the kidney represents a major target organ in antiphospholipid syndrome (APS), renal involvement in APS was poorly recognized until recently. The most well-recognized renal manifestations of APS are the renal artery thrombosis/stenosis, renal infarction, hypertension, renal vein thrombosis, end-stage renal disease, increased allograft vascular thrombosis, some types of glomerular disease, and a small-vessel vaso-occlusive nephropathy, recently defined as APS nephropathy. APS nephropathy was first described in primary APS patients, characterized by acute thrombotic lesions in glomeruli and/or arterioles (thrombotic microangiopathy) and chronic vascular lesions such as fibrous intimal hyperplasia of arterioles and interlobular arteries, organized thrombi with or without recanalization, and fibrous arterial and arteriolar occlusions or focal cortical atrophy. APS nephropathy was also detected in further studies including patients with systemic lupus erythematosus (SLE)-related APS and SLE/non-APS patients with positive antiphospholipid antibodies, independently of lupus nephritis. The same histologic lesions, especially thrombotic mictroangiopathy, were also observed in patients with catastrophic APS. The most frequent clinical and laboratory characteristics of APS nephropathy in all the above groups of patients are hypertension (often severe), proteinuria (ranging from mild to nephrotic range), hematuria, and acute or chronic renal insufficiency.
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Praprotnik S, Ferluga D, Vizjak A, Hvala A, Avčin T, Rozman B. Microthrombotic/Microangiopathic Manifestations of the Antiphospholipid Syndrome. Clin Rev Allergy Immunol 2008; 36:109-25. [DOI: 10.1007/s12016-008-8104-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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16
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Presotto F, Fornasini F, Betterle C, Federspil G, Rossato M. Acute adrenal failure as the heralding symptom of primary antiphospholipid syndrome: report of a case and review of the literature. Eur J Endocrinol 2005; 153:507-14. [PMID: 16189171 DOI: 10.1530/eje.1.02002] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Acute adrenal failure is a potentially fatal condition if overlooked. Occasionally, acute adrenal insufficiency may ensue from bilateral adrenal haemorrhage in patients with known antiphospholipid syndrome (APS). APS is characterized by recurrent arterial and venous thrombosis, pregnancy complications and detection of autoantibodies to phospholipids. This syndrome may be associated with non-organ specific diseases (e.g. connective tissue disorders) or with malignancies, but it may also appear in isolated form (primary APS). In a very few cases the heralding manifestation is given by adrenal failure. We report here a 63-year-old man presenting with acute adrenal insufficiency as the opening clinical manifestation of an APS. We also carried out a computer-aided search of the literature to identify all cases of primary adrenal failure as the first-recognized expression of a primary APS, a condition that not so infrequently may be tackled by endocrinologists. 20 patients fulfilled the inclusion criteria. The great majority of them were males (75%) with a mean age of 42 years. Abdominal pain was present in 14 patients, followed by fever (13 patients) and hypotension (12 patients). The main morphological findings by computed tomography or magnetic resonance were consistent with bilateral adrenal haemorrhage in 11 patients. Lupus anticoagulant was present in all of the 19 tested patients. Our observations emphasize the importance in the assessment of clotting times, and possibly of antiphospholipid antibodies, in all patients with diagnosis of rapidly progressive adrenal failure and concurrent abdominal pain.
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Affiliation(s)
- Fabio Presotto
- Third Division of Internal Medicine, Department of Medical and Surgical Sciences, University of Padua School of Medicine, I-35128, Padua, Italy.
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Gerner P, Heldmann M, Borusiak P, Bures V, Wirth S. Adrenal failure followed by status epilepticus and hemolytic anemia in primary antiphospholipid syndrome. Thromb J 2005; 3:6. [PMID: 15836793 PMCID: PMC1087888 DOI: 10.1186/1477-9560-3-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2004] [Accepted: 04/18/2005] [Indexed: 11/22/2022] Open
Abstract
We report on a 14 year old boy who presented with the symptoms abdominal pain, fever and proteinuria. A hematoma in the region of the right pararenal space was diagnosed. Prothrombin time and activated partial thromboplastin time were prolonged, lupus anticoagulant and anticardiolipin antibodies were positive and serum cortisol was normal. Ten days after admission the boy suddenly suffered generalized seizures due to low serum sodium. As well, the patient developed hemolytic anemia, acute elevated liver enzymes, hematuria and increased proteinuria. At this time a second hemorrhage of the left adrenal gland was documented. Adrenal function tests revealed adrenal insufficiency. We suspected microthromboses in the adrenals and secondary bleeding and treated the boy with hydrocortisone, fludrocortisone and phenprocoumon.
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Affiliation(s)
- Patrick Gerner
- Children's Hospital, HELIOS Klinikum Wuppertal, Witten-Herdecke University, Germany
| | - Michael Heldmann
- Children's Hospital, HELIOS Klinikum Wuppertal, Witten-Herdecke University, Germany
| | - Peter Borusiak
- Children's Hospital, HELIOS Klinikum Wuppertal, Witten-Herdecke University, Germany
| | - Vladimir Bures
- Department of Radiology, HELIOS Klinikum Wuppertal, Witten-Herdecke University, Germany
| | - Stefan Wirth
- Children's Hospital, HELIOS Klinikum Wuppertal, Witten-Herdecke University, Germany
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Espinosa G, Santos E, Cervera R, Piette JC, de la Red G, Gil V, Font J, Couch R, Ingelmo M, Asherson RA. Adrenal involvement in the antiphospholipid syndrome: clinical and immunologic characteristics of 86 patients. Medicine (Baltimore) 2003; 82:106-18. [PMID: 12640187 DOI: 10.1097/00005792-200303000-00005] [Citation(s) in RCA: 136] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To describe the clinical and immunologic characteristics of patients with adrenal involvement and antiphospholipid syndrome (APS), we conducted a computer-assisted (PubMed) search of the literature to identify all cases of primary adrenal insufficiency associated with antiphospholipid antibodies published in English, French, and Spanish from 1983 (when APS was first defined) through March 2002. We reviewed 86 patients (80 from the literature plus 6 from our cohort); 55% were male, and the mean age at presentation was 43 +/- 16 years. Sixty-one (71%) patients had primary APS, and 14 (16%) had systemic lupus erythematosus. In 31 (36%) patients, adrenal insufficiency was the first clinical manifestation of APS. Abdominal pain was present in 55% of patients, followed by hypotension (54%), fever (40%), nausea or vomiting (31%), weakness or fatigue (31%), and lethargy or altered mental status (19%). The main finding in imaging techniques was compatible with adrenal hemorrhage (59%) and in histopathologic study was a hemorrhagic infarction with vessel thrombosis (55%). Lupus anticoagulant was detected in 97% of patients and the anticardiolipin antibodies titer was positive in 93% of patients. Most patients (95%) were positive for the IgG isotype of anticardiolipin antibodies, whereas 40% were positive for the IgM isotype. Baseline cortisol levels were decreased in 98% of patients, ACTH hormone levels were increased in 96% of patients, and the cosyntropin stimulation test was positive in 100% of patients tested. Steroid replacement therapy was the most frequent treatment (84%), followed by anticoagulation (52%) and aspirin (6%). Thirty-two of 35 (91%) patients with prolonged anticoagulant therapy were in good health with a mean follow-up of 25 months, whereas 25 of the 69 (36%) patients with outcome data available had died. The results of the present review stress the clinical importance of systematic screening for lupus anticoagulant and anticardiolipin antibodies in all cases of adrenal hemorrhage or infarction. An initial screening for hypoadrenalism is mandatory in any antiphospholipid antibody-positive patient who complains of abdominal pain and undue weakness or asthenia.
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Affiliation(s)
- Gerard Espinosa
- Department of Autoimmune Diseases, Institut Clínic d'Infeccions i Immunologia, Institut d'Investigacions Biomèdiques August Pi Sunyer, Hospital Clínic, Barcelona, Catalonia, Spain
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Takebayashi K, Aso Y, Tayama K, Takemura Y, Inukai T. Primary antiphospholipid syndrome associated with acute adrenal failure. Am J Med Sci 2003; 325:41-4. [PMID: 12544085 DOI: 10.1097/00000441-200301000-00009] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We describe a 48-year-old woman with primary antiphospholipid syndrome who developed acute adrenal failure after an operation for a uterine myoma. After surgery, she developed a preshock state with hypotension, hypoglycemia, and hyponatremia. A diagnosis of primary antiphospholipid syndrome was made based not only on her past history of skin ulceration and recurrent spontaneous abortions but also on the presence of anticardiolipin antibodies. An abdominal computed tomography showed a bilateral enlargement of the adrenal glands but no high-density region in either gland. The patient recovered from the shock-like syndromes after the administration of glucocorticoids. Because it is possible that patients with antiphospholipid syndrome have acute or chronic adrenal failure caused by repeated hemorrhage or thrombosis, it may be important to monitor adrenal function in patients when the presence of this antibody is detected.
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Affiliation(s)
- K Takebayashi
- Department of Medicine, Koshigaya Hospital, Dokkyo University School of Medicine, Koshigaya, Japan.
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Abstract
CAPS is characterized by development of widespread microvascular thrombosis. Patients at risk are those with positive aCL or LA factor. Precipitating events, such as infection, trauma, surgical procedures, or reduction in anticoagulation therapy, may contribute to the development of CAPS. Presentation to the ICU can be dramatic, with progressive multiorgan failure and need for rapid institution of life-supporting measures. Cardiopulmonary failure has been the major contributor to mortality. A variety of therapeutic modalities have been used in an attempt to offset the widespread thrombosis and organ damage from high aCL levels. Anticoagulation therapy and high dosages of steroids seem to have a positive effect on survival.
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Affiliation(s)
- Gloria E Westney
- Pulmonary/Critical Care Section, Department of Medicine, Morehouse School of Medicine, 720 Westview Drive SW, Atlanta, GA 30310, USA.
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Furuta A, Fujii T, Yasuoka H, Takada R, Hirakata M, Mimori T. Severe hypertension associated with multiple intrarenal microaneurysms in a patient with systemic lupus erythematosus and antiphospholipid antibodies. Mod Rheumatol 2002; 12:178-81. [PMID: 24383908 DOI: 10.3109/s101650200030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract A 26-year-old Japanese woman with systemic lupus erythematosus (SLE) developed severe hyperten-sion and an increased active renin concentration (ARC), ischemic colitis, and splenic infarction. She had antiphospholipid antibodies (APA), multiple intrarenal microaneurysms, and multiple stenoses of the mesenteric arteries. Combination therapy with antihypertensive agents, aspirin, warfarin, and corticosteroids (30 mg daily) controlled her abdominal symptoms and hypertension. Multiple intrarenal microaneurysms in SLE with APA may be the cause of severe hypertension and elevated serum ARC.
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Affiliation(s)
- A Furuta
- Department of Internal Medicine, Keio University School of Medicine , Tokyo , Japan
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Purandare A, Godil MA, Prakash D, Parker R, Zerah M, Wilson TA. Spontaneous adrenal hemorrhage associated with transient antiphospholipid antibody in a child. Clin Pediatr (Phila) 2001; 40:347-50. [PMID: 11824179 DOI: 10.1177/000992280104000608] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- A Purandare
- Divisions of Endocrinology, State University of New York, Stony Brook, NY 11794-8111, USA
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23
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Affiliation(s)
- M G Clemens
- Department of Biology, University of North Carolina at Charlotte, Charlotte NC, USA.
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24
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Asherson RA, Cervera R, Piette JC, Font J, Lie JT, Burcoglu A, Lim K, Muñoz-Rodríguez FJ, Levy RA, Boué F, Rossert J, Ingelmo M. Catastrophic antiphospholipid syndrome. Clinical and laboratory features of 50 patients. Medicine (Baltimore) 1998; 77:195-207. [PMID: 9653431 DOI: 10.1097/00005792-199805000-00005] [Citation(s) in RCA: 331] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
We analyzed the clinical and laboratory characteristics of 50 patients with catastrophic antiphospholipid syndrome (APS) (5 from our clinics and 45 from a MEDLINE computer-assisted review of the literature from 1992 through 1996). Thirty-three (66%) patients were female and 17 (34%) were male. Twenty-eight (56%) patients had primary APS, 15 (30%) had defined systemic lupus erythematosus (SLE), 6 (12%) had "lupus-like" syndrome, and 1 (2%) had rheumatoid arthritis. Mean age of patients in this series was 38 +/- 14 years (range, 11-74 yr). Three (6%) patients developed the clinical picture of catastrophic APS under the age of 15 years, and 11 (22%) were 50 years old or more. In 11 (22%) patients, precipitating factors contributed to the development of catastrophic APS (infections in 3, drugs in 3, minor surgical procedures in 3, anticoagulation withdrawal in 2, and hysterectomy in 1). The presentation of the acute multi-organ failure was usually complex, involving multiple organs simultaneously or in a very short period of time. The majority of patients manifested microangiopathy--that is, occlusive vascular disease affecting predominantly small vessels of organs, particularly kidney, lungs, brain, heart, and liver--with a minority of patients experiencing only large vessel occlusions. Thrombocytopenia was reported in 34 (68%) patients, hemolytic anemia in 13 (26%), disseminated intravascular coagulation in 14 (28%), and schistocytes in 7 (14%). The following antibodies were detected: lupus anticoagulant (94%), anticardiolipin antibodies (94%), anti-dsDNA (87% of patients with SLE), antinuclear antibodies (58%), anti-Ro/SS-A (8%), anti-RNP (8%), and anti-La/SS-B (2%). Anticoagulation was used in 70% of the patients, steroids in 70%, plasmapheresis in 40%, cyclophosphamide in 34%, intravenous gammaglobulins in 16%, and splenectomy in 4%. Most patients, however, received a combination of nonsurgical therapies. Death occurred in 25 of the 50 (50%) patients. In most, cardiac problems seemed to be the major cause of death. In several of these, respiratory failure was also present, usually due to acute respiratory distress syndrome and diffuse alveolar hemorrhage. Among the 20 patients who received the combination of anticoagulation, steroids, and plasmapheresis or intravenous gammaglobulins, recovery occurred in 14 (70%) patients. The use of ancrod and defibrotide appeared to be effective in the 2 respective patients in whom they were used.
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Affiliation(s)
- R A Asherson
- Rheumatic Diseases Unit, University of Cape Town School of Medicine, South Africa
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Abstract
The antiphospholipid antibody syndrome is characterized by the association between recurrent arterial or venous thrombosis and the presence of circulating antiphospholipid antibodies. Antiphospholipid antibody-related thrombosis seems to constitute a significant proportion of childhood thromboses. About one third of children suffering a thrombotic event have circulating antiphospholipid antibodies, and more than two thirds of children with idiopathic cerebral ischemia meet the criteria for the diagnosis of antiphospholipid antibody syndrome. Because the other risk factors for thrombosis commonly found in adults have no impact on the pediatric patient, the risk for thrombosis and thrombotic recurrences and the optimal anticoagulation therapy may differ from adults.
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Affiliation(s)
- A Ravelli
- Clinica Pediatrica dell'Università, Istituto di Ricovero e Cura e Carattere Scientifico S. Matteo, Pavia, Italy
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Abstract
OBJECTIVE Adrenal insufficiency (AI) is a rare complication of the antiphospholipid antibody syndrome (APS). The objective of this report is to describe a case and review the published literature to enhance recognition of this potentially fatal disorder by emphasizing its course, diagnosis, and cause. DATA SOURCES A bibliographic database with the indexing terms adrenal insufficiency, adrenal hemorrhage, adrenal thrombosis, APS, systemic lupus erythematosus, with the constraints of human subjects only, was used. STUDY SELECTION All 27 reports meeting the indexing terms were selected for review. DATA EXTRACTION The specific criteria used for data extraction articles included course of the disease, causation, clinical and laboratory diagnostic criteria, and therapeutic intervention. DATA SYNTHESIS Our patient is a previously health woman who developed a respiratory tract infection, followed by a prolonged illness with fever, hypotension, nausea, depression, and venous thromboses. She was found to have AI and APS that was alleviated with hydrocortisone and anticoagulation. Initially, her adrenal glands were normal on CT scan but subsequently became enlarged and later atrophic. Of the 27 previous case reports, a majority had thromboses and typical clinical and laboratory manifestations of AI. Hemorrhagic infarction of the adrenal gland appears to be the mechanism for AI in the APS. IgG and IgM anticardiolipin antibodies are most commonly reported in association with AI in APS. CONCLUSIONS The hypercoagulable state in the APS may lead to adrenal vein thrombosis and subsequently to hemorrhagic necrosis of the adrenal gland. This complication of APS is important to recognize because it may be fatal if untreated.
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Affiliation(s)
- J A Arnason
- Department of Internal Medicine, University of Wisconsin, Madison 53972, USA
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Hughson MD, McCarty GA, Brumback RA. Spectrum of vascular pathology affecting patients with the antiphospholipid syndrome. Hum Pathol 1995; 26:716-24. [PMID: 7628842 DOI: 10.1016/0046-8177(95)90218-x] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
A thrombotic microangiopathy that is identified in patients with the antiphospholipid syndrome (APS) represents only a part of the vascular pathology that can be associated with antiphospholipid antibodies (aPL). Tissues from two autopsies, four renal biopsies, two skin biopsies, and one amputated leg were obtained from six patients who met criteria for the diagnosis of APS. Three patients had systemic lupus erythematosus (SLE), one had lupus-like disease, and two had a primary APS. Five of the patients were hypertensive. Arteries of three patients disclosed fibrin thrombi along with widespread obstruction by recanalized intimal connective tissue. Small renal, leptomeningeal, and pulmonary arteries showed concentric cellular and fibrous intimal hyperplasia indistinguishable from hypertensive vascular disease. Glomerular capillary and afferent arteriolar thrombi were found in renal biopsies from two SLE patients. One of these SLE patients required a leg amputation in which the popliteal artery demonstrated thrombosis, intimal hyperplasia, and acute inflammation. The findings support clinical and experimental data that indicate aPLs cause thrombosis but suggest diversity in the pathogenetic mechanisms aPLs are capable of promoting. Inflammation seems to be rare and to accompany thrombosis. Intimal hyperplasia is particularly common. Its involvement of renal arteries may contribute to hypertension that develops in some APS patients.
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Affiliation(s)
- M D Hughson
- Department of Pathology, Department of Veterans Affairs Medical Center, Northport, NY 11768-2290, USA
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Cervera R, Asherson RA, Lie JT. Clinicopathologic correlations of the antiphospholipid syndrome. Semin Arthritis Rheum 1995; 24:262-72. [PMID: 7740306 DOI: 10.1016/s0049-0172(95)80036-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Since the original description and definition of the antiphospholipid syndrome (APS), a number of distinct clinical manifestations related to it have appeared in the literature. These include vascular obstruction of both veins and arteries, thrombus formation on the endocardium and its consequences, as well as a group of other conditions where vascular obstructive mechanisms are either incompletely understood or unproven, eg, chorea, avascular necrosis, and pulmonary hypertension. Single vessel (large/medium) involvement or multiple vascular occlusions may cause a wide variety of presentations. Any combination of vascular occlusive events may occur in the same individual, and the time interval between them also varies considerably from weeks to months or even years. Rapid chronological occlusive events occurring over days to weeks have been termed the "catastrophic" APS. Most of these complications may be ascribed to the hypercoagulable state of which antiphospholipid antibodies appear either to be "markers" or intimately connected with the highly complex coagulation mechanisms resulting in thrombotic occlusions.
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Affiliation(s)
- R Cervera
- Department of Internal Medicine, Hospital Clínic, Barcelona, Catalonia, Spain
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Abstract
A systematic review of the etiopathogenesis of adrenal hemorrhage reveals that the factors that determine the occurrence of this complication in a patient can be identified prospectively. Such prospective diagnostic suspicion allows the significance of the otherwise nonspecific clinical features heralding this catastrophe to be appreciated in the precrisis interval. Confirmation of the diagnosis is achieved by visual demonstration of bilaterally enlarged and hyperdense adrenal glands on a CT scan and by demonstration of adrenocortical failure on hormonal evaluation. Preemptive steroid therapy and diagnostic evaluation during the precrisis period prevent the occurrence of a potentially disastrous adrenal crisis in a patient who is seriously ill from other problems and who cannot afford a setback of this severity. Because steroid therapy delayed until the stage of crisis may be unsuccessful in salvaging such a patient, prospective recognition must be based on identifying the patient at risk for BMAH and recognizing the significance of the nonspecific clinical features that accompany it in the appropriate clinical context.
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Affiliation(s)
- R H Rao
- Division of Endocrinology and Metabolism, University of Pittsburgh School of Medicine, Pennsylvania
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Durand JM, Lefevre P, Kaplanski G, Casanova P, Soubeyrand J. Accelerated hypertension and nephroangiosclerosis associated with antiphospholipid syndrome. Report of two cases and review of the literature. Clin Rheumatol 1994; 13:635-40. [PMID: 7697970 DOI: 10.1007/bf02243009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
We describe two patients with the primary antiphospholipid syndrome who presented with severe hypertension. Renal biopsy specimen provided histologic evidence of intra-renal vascular disease with intravascular microthrombosis and nephrosclerosis, without feature of proliferative glomerulopathy. Accelerated hypertension and nephroangiosclerosis might indeed be one of the complications associated with anticardiolipin antibodies. The mechanism responsible might be the interaction of anticardiolipin antibodies, platelets and endothelial cell leading to microthrombi formation and increased local mitogenic activity that attract and stimulate neighbouring smooth muscle cell and fibroblast proliferation.
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Affiliation(s)
- J M Durand
- Department of Internal Medicine, CHU Sainte-Marguerite, Marseille, France
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Affiliation(s)
- R A Asherson
- Lupus Arthritis Research Unit, Rayne Institute, St Thomas's Hospital, London, United Kingdom
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