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Jiang W, Chen D, Yang D, Zeng L, Xu W, Lin S. Adrenal Hemorrhage in Patients with Systemic Lupus Erythematosus and Antiphospholipid Syndrome: A Case Report and Literature Review. Int J Endocrinol 2023; 2023:6686168. [PMID: 37794979 PMCID: PMC10547568 DOI: 10.1155/2023/6686168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 09/04/2023] [Accepted: 09/12/2023] [Indexed: 10/06/2023] Open
Abstract
Antiphospholipid syndrome (APS) is an autoimmune disorder while adrenal hemorrhage could be its rare complication. Herein, we report the case of a 32-year-old unmarried woman with a history of systemic lupus erythematosus (SLE) who was hospitalized after complaints of upper abdominal pain, limb weakness, and loss of appetite for 2 weeks. Laboratory examination revealed hyponatremia, low plasma cortisol levels, increased adrenocorticotropic hormone levels, and a positive anticardiolipin antibody status. Furthermore, computed tomography (CT) revealed the presence of bilateral adrenal masses. Ultimately, based on dynamic changes in CT images, these masses were diagnosed as adrenal hemorrhage owing to APS. A computer-assisted literature search was conducted to identify cases of primary adrenal insufficiency associated with APS and/or SLE. The clinical features, laboratory examination, treatments, and outcomes of these cases were summarized. Our findings emphasize the importance of screening for adrenal insufficiency in patients with SLE or APS who present with abdominal complaints, asthenia, and hyponatremia. It is also recommended to test for APS all patients with adrenal hemorrhage.
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Affiliation(s)
- Weiwei Jiang
- Department of Endocrinology & Metabolism, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Danrui Chen
- Department of Endocrinology & Metabolism, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Daizhi Yang
- Department of Endocrinology & Metabolism, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of Diabetology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- Guangzhou Municipal Key Laboratory of Mechanistic and Translational Obesity Research, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Longyi Zeng
- Department of Endocrinology & Metabolism, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of Diabetology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- Guangzhou Municipal Key Laboratory of Mechanistic and Translational Obesity Research, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Wen Xu
- Department of Endocrinology & Metabolism, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of Diabetology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- Guangzhou Municipal Key Laboratory of Mechanistic and Translational Obesity Research, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Shuo Lin
- Department of Endocrinology & Metabolism, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of Diabetology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- Guangzhou Municipal Key Laboratory of Mechanistic and Translational Obesity Research, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
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Gligorijevic N, Kaljevic M, Radovanovic N, Jovanovic F, Joksimovic B, Singh S, Dumic I. Adrenal Abscesses: A Systematic Review of the Literature. J Clin Med 2023; 12:4601. [PMID: 37510716 PMCID: PMC10380332 DOI: 10.3390/jcm12144601] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 07/01/2023] [Accepted: 07/05/2023] [Indexed: 07/30/2023] Open
Abstract
Objective: To summarize the existing knowledge about adrenal gland abscesses, including etiology, clinical presentation, common laboratory and imaging findings, management and overall morbidity and mortality. Design: Systematic literature review. Methods: We performed a search in the PubMed database using search terms: 'abscess and adrenal glands', 'adrenalitis', 'infection and adrenal gland', 'adrenal abscess', 'adrenal infection' and 'infectious adrenalitis'. Articles from 2017 to 2022 were included. We found total of 116 articles, and after applying exclusion criteria, data from 73 articles was included in the final statistical analysis. Results: Of 84 patients included in this review, 68 were male (81%), with a mean age of 55 years (range: 29 to 85 years). Weight loss was the most frequent symptom reported in 58.3% patients, followed by fever in 49%. Mean duration of symptoms was 4.5 months. The most common laboratory findings were low cortisol (51.9%), elevated ACTH (43.2%), hyponatremia (88.2%) and anemia (83.3%). Adrenal cultures were positive in 86.4% cases, with Histoplasma capsulatum (37.3%) being the leading causative agent. Blood cultures were positive in 30% of patients. The majority of the adrenal infections occurred through secondary dissemination from other infectious foci and abscesses were more commonly bilateral (70%). A total of 46.4% of patients developed long-term adrenal insufficiency requiring treatment. Abscess drainage was performed in 7 patients (8.3%) and adrenalectomy was performed in 18 (21.4%) patients. The survival rate was 92.9%. Multivariate analysis showed that the only independent risk factor for mortality was thrombocytopenia (p = 0.048). Conclusion: Our review shows that adrenal abscesses are usually caused by fungal pathogens, and among these, Histoplasma capsulatum is the most common. The adrenal glands are usually involved in a bilateral fashion and become infected through dissemination from other primary sources of infection. Long-term adrenal insufficiency develops in 46% of patients, which is more common than what is observed in non-infectious etiology of adrenal gland disorders. Mortality is about 7%, and the presence of thrombocytopenia is associated with worse prognosis. Further prospective studies are needed to better characterize optimal testing and treatment duration in patients with this relatively rare but challenging disorder.
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Affiliation(s)
- Nikola Gligorijevic
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Marija Kaljevic
- Department of Hospital Medicine, Saint Francis Hospital and Medical Center, Hartford, CT 06105, USA
- Division of Internal Medicine, University of Connecticut, Farmington, CT 06030, USA
| | - Natasa Radovanovic
- Department of Endocrinology, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine, Dartmouth College, Hanover, NH 03755, USA
| | - Filip Jovanovic
- Department of Internal Medicine, Merit Health Wesley, Hattiesburg, MS 39402, USA
| | - Bojan Joksimovic
- Department of Pathological Physiology, Faculty of Medicine Foca, University of East Sarajevo, 73300 Foca, Bosnia and Herzegovina
| | - Sandra Singh
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Igor Dumic
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA
- Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
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Diana H, Diana R, Daniela R, Oscar L. Adrenal crisis as initial manifestation of bilateral adrenal hemorrhage due to antiphospholipid syndrome: A case report. SAGE Open Med Case Rep 2023; 11:2050313X231181653. [PMID: 37359285 PMCID: PMC10286198 DOI: 10.1177/2050313x231181653] [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: 12/10/2022] [Accepted: 05/24/2023] [Indexed: 06/28/2023] Open
Abstract
A 62-year-old man was admitted to the emergency department with hypotension and altered consciousness. On physical examination, he had hyperpigmentation of the skin and mucous membranes. Admission tests revealed hypoglycemia, hyponatremia, and hyperkalemia. Fluid resuscitation was initiated with no improvement in blood pressure. Because adrenal crisis was suspected, blood samples for cortisol and adrenocorticotropic hormone were collected before commencing hydrocortisone, after which blood pressure improved and electrolyte disturbances disappeared. The tests revealed decreased serum cortisol and an increase in adrenocorticotropic hormone. A magnetic resonance imaging scan of the abdomen revealed evidence of bilateral adrenal hemorrhage. Positive antiphospholipid antibodies were detected during the investigations. This case underscores the importance of prompt evaluation of clinical signs and symptoms that may indicate adrenal crisis.
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Affiliation(s)
- Henao Diana
- Fundación Universitaria de Ciencias de la Salud, Bogotá, Colombia
- Pontificia Universidad Javeriana—Hospital Universitario San Ignacio, Bogotá, Colombia
| | - Romero Diana
- Internal Medicine, Endocrinology Unit, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Rosero Daniela
- Pontificia Universidad Javeriana—Hospital Universitario San Ignacio, Bogotá, Colombia
| | - Lucero Oscar
- Internal Medicine, Endocrinology Unit, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogotá, Colombia
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Addison's Disease in the Course of Recurrent Microangiopathic Antiphospholipid Syndrome-A Clinical Presentation and Review of the Literature. Medicina (B Aires) 2022; 59:medicina59010004. [PMID: 36676628 PMCID: PMC9863237 DOI: 10.3390/medicina59010004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/14/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
The article presents a male patient with adrenocortical insufficiency in the course of antiphospholipid syndrome (APS). It also describes recurrent exacerbations of his clinical status, characteristic of microangiopathic antiphospholipid syndrome (MAPS) which had been misdiagnosed as a disseminated intravascular coagulopathy (DIC) syndrome due to sepsis with multi-organ failure, including heart, kidneys, and liver. Issues related to pathogenesis, clinical symptoms, differential diagnosis, and treatment of APS in the context of presently distinguished subtypes of this syndrome have been addressed. The role of vascular endothelial cell activation and the influence of coagulation patterns on the development of APS continuum clinical symptoms have also been mentioned. In addition, this paper highlights that the diagnosis of APS should be considered in patients with adrenal insufficiency and abdominal pain, even without any prior history of thromboembolic diseases, as well as in the course of DIC, especially without predisposing factors.
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Hematologic Disorders and Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00042-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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6
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Cecchi I, Radin M, Rubini E, Foddai SG, Barinotti A, Roccatello D, Sciascia S. Clinical manifestations in patients with antiphospholipid antibodies: Beyond thrombosis and pregnancy loss. Lupus 2021; 30:884-892. [PMID: 33593163 DOI: 10.1177/0961203321995248] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The clinical spectrum of the antiphospholipid syndrome (APS) encompasses additional manifestations other than thrombosis and pregnancy morbidity, which may potentially affect every organ and system. The pathophysiology of APS indeed cannot be explained exclusively by a prothrombotic state and the "extra-criteria" manifestations of the syndrome should be attributed to other mechanisms, such as inflammation, complement and platelet activation. In this case-series, we report patients with uncommon clinical APS presentations, to highlight relevant peculiarities of the syndrome, potentially paving the way for a further update of clinical as well as laboratory manifestations of this complex immunological condition.
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Affiliation(s)
- Irene Cecchi
- Center of Research of Immunopathology and Rare Diseases - Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Massimo Radin
- Center of Research of Immunopathology and Rare Diseases - Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Elena Rubini
- Center of Research of Immunopathology and Rare Diseases - Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Silvia G Foddai
- Center of Research of Immunopathology and Rare Diseases - Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy.,Department of Clinical and Biological Sciences, School of Specialization of Clinical Pathology, University of Turin, Turin, Italy
| | - Alice Barinotti
- Center of Research of Immunopathology and Rare Diseases - Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy.,Department of Clinical and Biological Sciences, School of Specialization of Clinical Pathology, University of Turin, Turin, Italy
| | - Dario Roccatello
- Center of Research of Immunopathology and Rare Diseases - Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy.,Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy
| | - Savino Sciascia
- Center of Research of Immunopathology and Rare Diseases - Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy.,Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy
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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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Medina G, Jiménez-Arellano MP, Muñoz-Solís A, Servín-Torres E, Ramírez-Mendoza P, Jara LJ. Primary antiphospholipid syndrome, Addison disease, and adrenal incidentaloma. Clin Rheumatol 2020; 39:1997-2001. [PMID: 32146613 DOI: 10.1007/s10067-020-04978-9] [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: 09/27/2019] [Revised: 02/04/2020] [Accepted: 02/07/2020] [Indexed: 11/29/2022]
Abstract
Primary adrenal failure comprises an insufficient production of mineralocorticoids and glucocorticoids in the adrenal cortex. A rare manifestation of antiphospholipid syndrome (APS) is adrenal failure. The majority of patients with adrenal involvement in APS develop an irreversible cortisol deficiency and atrophy of the adrenal glands. Adrenal incidentalomas are adrenal masses larger than 1 cm that are discovered in the course of diagnostic evaluation or treatment for another medical condition. Its prevalence is calculated in 1.5-9% of individuals. We describe an exceptional case of a 23-year-old male patient with APS with persistent high levels of antiphospholipid antibodies (aPL) from the time of diagnosis, who developed Addison's disease as a manifestation of APS with atrophy of the adrenal glands, in whom an adrenal incidentaloma was developed later and was corroborated as an aldosterone-producing adenoma. Currently, the patient is asymptomatic and without manifestations of tumor recurrence. The protumoral effect of elevated and persistent aPL is discussed.
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Affiliation(s)
- Gabriela Medina
- Translational Research Unit, Hospital de Especialidades, Centro Médico Nacional "La Raza," IMSS, Mexico City, Mexico
| | | | - Andrés Muñoz-Solís
- Endocrinology Department, Hospital de Especialidades, Centro Médico Nacional "La Raza," IMSS, Mexico City, Mexico
| | - Erick Servín-Torres
- Surgery Department, Hospital de Especialidades, Centro Médico Nacional "La Raza," IMSS, Mexico City, Mexico
| | - Pablo Ramírez-Mendoza
- Pathology Department, Hospital de Especialidades, Centro Médico Nacional "La Raza," IMSS, Mexico City, Mexico
| | - Luis J Jara
- Direction of Education and Research, Hospital de Especialidades, Centro Médico Nacional "La Raza," IMSS, Seris y Zaachila S/N Col. La Raza CP, 02990, Mexico City, Mexico.
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9
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Lee KH, Lee H, Lee CH, Kim JY, Kim JM, Kim SS, Jeong S, Hwang IS, Kim N, Kim NE, Shin S, Shin D, Song JS, Shin DH, Kim JD, Kim J, Lee YS, Kang H, Kim DH, Moon SH, Rho WS, Lee JY, Kronbichler A, Shin JI. Adrenal insufficiency in systematic lupus erythematosus (SLE) and antiphospholipid syndrome (APS): A systematic review. Autoimmun Rev 2018; 18:1-8. [PMID: 30408580 DOI: 10.1016/j.autrev.2018.06.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 06/18/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND Adrenal insufficiency (AI) is associated with high morbidity and mortality. The aim of this systematic review was to enhance diagnostic approaches and summarize therapeutic strategies in the management of AI in patients with systematic lupus erythematosus (SLE) or antiphospholipid syndrome (APS). METHODS A literature search of PubMed and Medline databases was performed and 91 publications containing 105 cases were included for the final analysis. RESULTS The following frequency of clinical signs and symptoms was noted: abdominal pain (39.04%) was the leading symptom, followed by fever (33.33%), vomiting (23.81%), and nausea (19.05%). APS was present in 73%, SLE in 17% of the patients, while 2% had a diagnosis of both, SLE and APS. ACTH stimulation test (ACTHst) was performed in 18% of cases and 76.6% of them were unresponsive towards stimulation. Variable treatment approaches were used: hydrocortisone was most commonly used (38.09%), followed by fludrocortisone (26.67%), prednisolone (20.00%) and volume replacement treatment (11.43%), respectively. CONCLUSIONS This analysis highlights the importance of an early diagnosis and initiation of therapeutic management when AI is suspected. In line, signs and symptoms related to autoimmune diseases in patients with AI should be reviewed crtitically.
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Affiliation(s)
- Keum Hwa Lee
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Republic of Korea; Division of Pediatric Nephrology, Severance Children's Hospital, Seoul, Republic of Korea
| | - HyunJeong Lee
- Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Cheol-Hun Lee
- Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jin Yeong Kim
- Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jong Min Kim
- Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Se Seung Kim
- Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seungmin Jeong
- Yonsei University College of Medicine, Seoul, Republic of Korea
| | - In Sung Hwang
- Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Namsoo Kim
- Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Na Eun Kim
- Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Soogeun Shin
- Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dongkwan Shin
- Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joo Sang Song
- Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dong Hyun Shin
- Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jung Dong Kim
- Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jeehoon Kim
- Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong Seok Lee
- Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hansung Kang
- Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dong Ha Kim
- Yonsei University College of Medicine, Seoul, Republic of Korea
| | - So Hyun Moon
- Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Won Suk Rho
- Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joo Yeon Lee
- Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Republic of Korea; Division of Pediatric Nephrology, Severance Children's Hospital, Seoul, Republic of Korea; Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Abstract
Catastrophic antiphospholipid syndrome is a rapidly progressive life-threatening disease that causes multiple organ thromboses and dysfunction in the presence of antiphospholipid antibodies. A high index of clinical suspicion and careful investigation are required to make an early diagnosis so that treatment with anticoagulation and corticosteroids can be initiated; plasma exchange and/or intravenous immunoglobulins can be added if the life-threatening condition persists. Despite aggressive treatment and intensive care unit management, patients with catastrophic antiphospholipid syndrome have a 48% mortality rate, primarily attributable to cardiopulmonary failure. This article reviews the current information on the etiopathogenesis, clinical manifestations, diagnosis, management, and prognosis of catastrophic antiphospholipid syndrome.
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Affiliation(s)
- Setu K Vora
- Pulmonary Physicians of Norwich, Norwich, Connecticut, USA
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Hematologic Disorders and Stroke. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00042-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Katikaneni M, Gangam M, Berney SM, Umer S. Antiphospholipid Syndrome (APS) - An Update on Clinical Features and Treatment Options. ACTA ACUST UNITED AC 2015. [DOI: 10.2174/1874303x01508020027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Antiphospholipid syndrome (APS) is an autoantibody disorder characterized by the presence of antiphospholipid (APL) antibodies and heterogeneous clinical manifestations. Patients may present with recurrent thrombosis, obstetric morbidity, cardiac valvular lesions, thrombocytopenia, skin lesions, renal or neurologic abnormalities. We provide a comprehensive review of these diverse clinical features except renal and obstetric complications. Treatment of APS can be challenging as one tries to balance the benefit of anticoagulation therapy in this hypercoagulable state while minimizing the risk of bleeding. We discuss the various therapeutic options including the role of aspirin, warfarin, low molecular weight heparin, new direct thrombin inhibitors, hydroxychloroquine, intravenous gamma globulin, rituximab and others. Lower risk APS patients (i.e. first venous thrombosis) should receive warfarin with a target INR of 2.0-3.0. Higher risk patients (i.e. arterial thrombosis or recurrent venous events) have a target INR of >3.0. Currently, warfarin remains the mainstay in treatment of APS. Because of lack of adequate data, the newer oral direct inhibitors should be considered only when there is a known allergy/ intolerance or poor control with warfarin. Additional vascular and thrombotic risk factors should be aggressively reduced. Further studies involving large number of APS patients, diagnosed according to accepted criteria, are needed to better define the role of newer anticoagulants and other novel therapies.
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Haselboeck J, Ringl H, Mueller C, Pabinger I, Winkler S. Post-surgical hemorrhagic infarction of the adrenal gland as the first clinical manifestation of antiphospholipid syndrome after 43 years of antibody-positivity. Mod Rheumatol 2014. [DOI: 10.3109/s10165-012-0741-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Behera KK, Kapoor N, Seshadri MS, Rajaratnam S. Acute adrenal insufficiency due to primary antiphospholipid antibody syndrome. Indian J Endocrinol Metab 2013; 17:S240-S242. [PMID: 24251172 PMCID: PMC3830318 DOI: 10.4103/2230-8210.119584] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION We report a case of acute adrenal insufficiency (AAI) in a patient with antiphospholipid syndrome (APS). CASE REPORT A 44-year-old female patient presented to us with acute abdominal pain associated with recurrent vomiting and giddiness. On examination, her blood pressure was 80/50 mm Hg. Systemic examination was normal. Further evaluation revealed hypocortisolemia with elevated plasma adrenocorticotropin hormone indicative of primary adrenal insufficiency. Her abdominal computed tomography scan showed features of evolving bilateral adrenal infarction. Etiological work-up revealed prolonged activated thromboplastin time, which didn't correct with normal plasma, her anti-cardiolipin antibody and lupus anticoagulant were also positive. She was diagnosed to have APS with adrenal insufficiency and she was started on intravenous steroids and heparin infusion. CONCLUSION AAI due to the APS can present with acute abdominal pain followed by hypotension. A high index of suspicion is needed to make the correct diagnosis and to initiate appropriate treatment.
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Affiliation(s)
- Kishore Kumar Behera
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Tamil Nadu, India
| | - Nitin Kapoor
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Tamil Nadu, India
| | - M. S. Seshadri
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Tamil Nadu, India
| | - Simon Rajaratnam
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Tamil Nadu, India
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Almiani M, Gorthi J, Subbiah S, Firoz M. Quiz page november 2012: an unusual case of acute hyponatremia and normal anion gap metabolic acidosis. Am J Kidney Dis 2012; 60:xxxiii-xxxvi. [PMID: 23067654 DOI: 10.1053/j.ajkd.2012.05.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Accepted: 05/24/2012] [Indexed: 11/11/2022]
Affiliation(s)
- Mohammad Almiani
- Department of Nephrology, University of Chicago Medical Center, Chicago, IL 60637, USA.
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Haselboeck J, Ringl H, Mueller C, Pabinger I, Winkler S. Post-surgical hemorrhagic infarction of the adrenal gland as the first clinical manifestation of antiphospholipid syndrome after 43 years of antibody-positivity. Mod Rheumatol 2012; 23:1237-41. [PMID: 22926769 DOI: 10.1007/s10165-012-0741-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Accepted: 08/06/2012] [Indexed: 11/26/2022]
Abstract
We report on a male patient who tested positive for antiphospholipid antibodies for 43 years without thromboembolic manifestation of antiphospholipid syndrome (APS). He has been followed up in a prospective cohort study since 2001. Following his second hip replacement surgery, the patient developed acute adrenal failure due to bilateral hemorrhagic infarction. Prophylactic anticoagulation, surgery, or an immunological reaction to blood transfusion may have triggered this late and unusually located primary manifestation of APS in our patient.
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Affiliation(s)
- Johanna Haselboeck
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
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17
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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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19
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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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20
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Primary antiphospholipid syndrome presenting as hyponatremic hypertensive syndrome and acute adrenal insufficiency following it: a rare case. Rheumatol Int 2009; 30:259-63. [DOI: 10.1007/s00296-009-0922-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2008] [Accepted: 03/27/2009] [Indexed: 11/26/2022]
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21
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Addison’s disease secondary to connective tissue diseases: a report of six cases. Rheumatol Int 2008; 29:647-50. [DOI: 10.1007/s00296-008-0749-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2008] [Accepted: 10/05/2008] [Indexed: 10/21/2022]
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22
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PAGALAVAN L. Antiphospholipid syndrome: a systemic and multidisciplinary disease. Int J Rheum Dis 2008. [DOI: 10.1111/j.1756-185x.2008.00343.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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23
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Rodríguez Carballeira M, de Juan C, Reverter JC. [Bilateral suprarenal hematoma in a 46-year-old male]. Med Clin (Barc) 2008; 130:71-7. [PMID: 18221678 DOI: 10.1157/13115030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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24
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Squizzato A, Gerdes VEA, Ageno W, Büller HR. The coagulation system in endocrine disorders: a narrative review. Intern Emerg Med 2007; 2:76-83. [PMID: 17657422 DOI: 10.1007/s11739-007-0026-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2006] [Accepted: 07/25/2006] [Indexed: 10/23/2022]
Abstract
Endocrine disorders can influence the haemostatic balance. Abnormal coagulation test results have been observed in patients with abnormal hormone levels. Also unprovoked bleeding or thrombotic events have been associated with endocrine disease. The aim of the present review is to summarise the available evidence on the influence of common endocrine disorders on the coagulation system, and their possible clinical implications. We focus on thyroid dysfunction, hyper- and hypocortisolism and growth hormone disturbances, while other endocrine disorders are only briefly discussed. In the published literature a clear bleeding diathesis has only been associated with overt hypothyroidism, mainly mediated by an acquired von Willebrand syndrome. A clinically relevant hypercoagulable state may be present in patients with hyperthyroidism, hypercortisolism or abnormal growth hormone levels, but adequate prospective clinical studies are lacking. Also effects of pheochromocytoma, hyperprolactinaemia and hyperaldosteronism on the coagulation system have been described. It is apparent that unprovoked bleeding and thrombotic episodes can be secondary to endocrine disorders.
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Affiliation(s)
- A Squizzato
- Department of Clinical Medicine, University of Insubria, Varese, Italy.
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25
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Law WG, Thong BYH, Umapathi T, Chng HH. Acute pan-dysautonomia: a rare initial presentation of lupus with sjogren's syndrome. Lupus 2007; 15:899-900. [PMID: 17211999 DOI: 10.1177/0961203306070984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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26
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Fujishima N, Komatsuda A, Ohyagi H, Fujishima M, Tada M, Ohtani H, Wakui H, Hirokawa M, Sawada KI. Adrenal insufficiency complicated with antiphospholipid syndrome (APS). Intern Med 2006; 45:963-6. [PMID: 16974059 DOI: 10.2169/internalmedicine.45.1603] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We describe a 69-year-old woman with bilateral adrenal hemorrhage complicated with antiphospholipid syndrome (APS). She was hospitalized with nausea and vomiting in September 2003. Laboratory data demonstrated hyponatremia, hypoglycemia and prolongation of activated partial thromboplastin time (aPTT). Abdominal computed tomography showed bilateral adrenal enlargement. In October 2003, she demonstrated altered mental status with progressive hyponatremia, a high level of ACTH, and a low level of serum cortisol. She also showed thrombocytopenia, anti-cardiolipin IgG antibody, anti-beta2GPI antibody, and lupus anticoagulants. After four months, anti-cardiolipin IgG antibody was still positive. Based on these findings, she was diagnosed as having APS complicated with adrenal insufficiency due to hemorrhagic infarction. After treatment with corticosteroid, a low dose of aspirin and normal saline infusion, her condition quickly improved. Platelet counts and aPTT were also normalized. To our knowledge, this is the second Japanese case of APS complicated with bilateral adrenal hemorrhage. APS should be considered an important underlying cause of adrenal insufficiency.
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Affiliation(s)
- Naohito Fujishima
- Third Department of Internal Medicine, Akita University School of Medicine
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Bhattacharya M, Yeh BM, Qayyum A, Coakley FV. Case 81: antiphospholipid antibody syndrome with adrenal hemorrhage and Budd-Chiari syndrome. Radiology 2005; 235:53-5. [PMID: 15798168 DOI: 10.1148/radiol.2351031848] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Mallar Bhattacharya
- Department of Radiology, University of California-San Francisco, Box 0628, M-372, 505 Parnassus Avenue, San Francisco, CA 94143-0628
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