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Gao L, Zhang L, Luo J, Zhang G, Shen Y, Wang Y, Li M. Clinical characteristics of systemic lupus erythematosus patients with adrenal hemorrhage. Clin Rheumatol 2024; 43:2223-2227. [PMID: 38724818 DOI: 10.1007/s10067-024-06938-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 02/13/2024] [Accepted: 03/13/2024] [Indexed: 06/19/2024]
Abstract
INTRODUCTION Adrenal hemorrhage (AH) is a rare condition and severe cases can lead to acute adrenal insufficiency with potentially life-threatening consequences. AH can be caused by a variety of etiologic factors, including systemic lupus erythematosus and antiphospholipid syndrome (APS). The early identification and treatment of these patients improves their prognosis. OBJECTIVE The aims of this study were to analyze and summarize the clinical characteristics of systemic lupus erythematosus patients with AH. METHODS The clinical characteristics of 6 systemic lupus erythematosus patients complicated with AH admitted to Peking Union Medical College Hospital and Beijing Shijitan Hospital from May 2004 to April 2022 were retrospectively analyzed. RESULTS The diagnosis of AH was based on computed tomography (CT) findings. Two patients had bilateral lesions, and the other 4 patients had unilateral lesions. The symptoms of adrenal insufficiency were observed in 2 patients. The frequent presenting symptoms were abdominal pain, lower abdominal distension, vomiting, weakness, fever, arthrodynia, and skin rash. Four patients had APS. Five patients (4 patients with APS and 1 patient without APS) had thromboembolic events. All patients received glucocorticoid and immunosuppressant therapy. Five patients were treated with anticoagulant therapy. Follow-up imaging examinations showed a partial or total regression of the lesions after treatment. CONCLUSIONS In the proper clinical setting, having high clinical suspicion for AH, early diagnosis and timely management is crucial to avoid life-threatening adrenal insufficiency. Key Points • AH is a rare condition and severe cases may lead to death. It can be caused by a variety of etiologic factors, including SLE. • In patients with SLE, especially combined with APS, if they complain of abdominal pain, particularly when common gastrointestinal involvement is difficult to explain, a high index of clinical suspicion is needed for the diagnosis of AH. • Early identification of AH in SLE patients can improve their prognosis.
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Affiliation(s)
- Lan Gao
- Department of Rheumatology and Clinical Immunology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Lingling Zhang
- Department of Rheumatology and Clinical Immunology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Junli Luo
- Department of Rheumatology and Clinical Immunology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Guohua Zhang
- Department of Rheumatology and Clinical Immunology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Yawen Shen
- Department of Rheumatology and Clinical Immunology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Yuhua Wang
- Department of Rheumatology and Clinical Immunology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China.
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.
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2
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Kim S, Horiuchi K, Arrazola E, Basnet A. Metastatic malignant melanoma presented as non-traumatic adrenal haemorrhage. BMJ Case Rep 2024; 17:e260227. [PMID: 38857916 DOI: 10.1136/bcr-2024-260227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2024] Open
Affiliation(s)
- Saehyeon Kim
- Department of Family Medicine, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Kohei Horiuchi
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Morningside and West, New York, New York, USA
| | - Edgardo Arrazola
- Department of Family Medicine, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Alina Basnet
- Upstate Cancer Center, Division of Hematology/Oncology, SUNY Upstate Medical University, Syracuse, New York, USA
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3
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Sakalkale A, Choi CCM, Krawitz R, Yeung JM. Two cases of atraumatic adrenal hemorrhage: A review of active management, conservative management, and challenges faced. Radiol Case Rep 2024; 19:2395-2401. [PMID: 38645544 PMCID: PMC11026934 DOI: 10.1016/j.radcr.2024.03.005] [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: 02/25/2024] [Revised: 02/28/2024] [Accepted: 03/05/2024] [Indexed: 04/23/2024] Open
Abstract
Adrenal hemorrhage (AH) is an uncommon and potentially disastrous affliction that carries an accepted mortality risk of 15%. Variable symptomatology can cause a diagnostic dilemma and may be missed. We present 2 cases of right-sided AH; both cases were initially presumed to be renal colic. Case 1 was an 86-year-old gentleman, presenting with right flank pain found to have a right-sided atraumatic AH. He presented with hemorrhagic shock, requiring angioembolization of the bleeding vessel. Case 2 was a 62-year-old gentleman who presented with right flank pain and was found to have a right-sided atraumatic AH. He was hemodynamically stable and successfully managed conservatively. Adrenal hemorrhage is a potentially fatal affliction that may be missed. CT scans are the recommended imaging modality during an acute presentation due to wider availability and fast assessment. We demonstrate a hemodynamically stable patient managed with a 'watch and wait' approach and an unstable patient managed with resuscitation followed by urgent angioembolization.
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Affiliation(s)
- Aditya Sakalkale
- Department of General Surgery, Western Health, Melbourne, Australia
| | | | - Russel Krawitz
- Department of General Surgery, Western Health, Melbourne, Australia
| | - Justin M.C. Yeung
- Department of Colorectal Surgery, Western Health, Melbourne, Australia
- Department of Surgery, Western Precinct, University of Melbourne, Melbourne, Australia
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Pokharel G, Rosales S, Morrison J, Kim C. A Case of Adrenal Insufficiency Secondary to Bilateral Adrenal Hemorrhage in a Patient With Antiphospholipid Antibody Syndrome and Epstein-Barr Virus Infection. Cureus 2024; 16:e63544. [PMID: 39086776 PMCID: PMC11289495 DOI: 10.7759/cureus.63544] [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] [Accepted: 06/30/2024] [Indexed: 08/02/2024] Open
Abstract
Bilateral adrenal hemorrhage (AH) is linked to various causes, including bacterial and viral infections, coagulopathies, and postoperative states. Symptoms can range from mild adrenal insufficiency to shock from Waterhouse-Friedrichsen syndrome. We present a case of a 47-year-old male with antiphospholipid antibody syndrome (APS) on warfarin who presented to the emergency department (ED) with bilateral flank pain and was found to have bilateral AH. On exam, he was hypertensive, mildly tachycardic, and in severe pain. The abdomen was tender over the bilateral flank and costovertebral regions. Labs showed thrombocytopenia but normal international normalized ratio (INR) and fibrinogen. The CT and MRI confirmed bilateral AH. Further investigations revealed low ante meridiem (AM) cortisol and elevated adrenocorticotropic hormone (ACTH). The antinuclear antibody (ANA) test was negative, but the antiphospholipid antibody panel was positive. In addition, the patient had a positive Epstein-Barr virus (EBV) nuclear antigen with a significant IgM titer. He was treated with low-dose steroids and was placed on a prophylactic dose of enoxaparin with the resolution of symptoms. At discharge, he was advised to follow up with a hematologist in six weeks to restart full-dose anticoagulation, allowing time for the bleeding to resolve. This case highlights EBV infection as a possible trigger of adrenal insufficiency from adrenal bleeding in a patient with preexisting coagulopathy, necessitating prompt recognition and treatment.
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Affiliation(s)
- Grishma Pokharel
- Internal Medicine, Englewood Hospital and Medical Center, Englewood, USA
| | - Stephanie Rosales
- Internal Medicine, Englewood Hospital and Medical Center, Englewood, USA
| | - Jill Morrison
- Hematology and Oncology, Englewood Hospital and Medical Center, Englewood, USA
| | - Christian Kim
- Endocrinology, Hackensack University and Medical Center, Hackensack, USA
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5
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van Aswegen T, Trinh B, Jacques A, Lo G. Adrenal washout CT in patients with no history of cancer: a waste of time? Abdom Radiol (NY) 2024:10.1007/s00261-024-04333-5. [PMID: 38772953 DOI: 10.1007/s00261-024-04333-5] [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: 12/08/2023] [Revised: 04/04/2024] [Accepted: 04/05/2024] [Indexed: 05/23/2024]
Abstract
PURPOSE To validate the diagnostic performance of adrenal washout CT in patients without known malignancy in a Western Australian population. METHODS A radiology information system (RIS) search for CT reports containing "adrenal" and "washout" across six networked metropolitan public hospitals between January 2005 and November 2021. Homogenous nodules ≥ 1 cm, ≥ 10 HU without a suspected functional component in patients without a history of malignancy were included. Reported absolute and relative washout percentages were recorded and re-measured from unenhanced, 60-s portal venous and 15-min delayed phase imaging and compared to either histopathological or CT follow up for growth (≥ 12 months) reference standards. RESULTS 2653 studies were screened with 191 meeting inclusion criteria. 105 nodules underwent washout CT and then had either histopathological (12 patients) or CT follow up (93 patients) reference standards available. Reported absolute washout (aWO) estimated sensitivity and specificity for malignant/indeterminate nodules was low at 33% (95% CI 25-43%) and 77% (95% CI 68-84%) respectively. Reported relative washout (rWO) sensitivity and specificity were 56% (95% CI 46-65%) and 69% (95% CI 60-77%) respectively. Negative predictive values for both aWO and rWO were reassuring at 92% (95% CI 86-96%) and 94% (95%CI 88-97%). CONCLUSION Our study validates a recent report suggesting that adrenal washout has poor sensitivity for and consequent limited utility to exclude malignancy in patients with no cancer history. However, patients with incidental adrenal nodules < 4 cm in size with benign washout can be reassured by the high negative predictive value and worked up to exclude functional adenoma and re-imaged in a year to confirm no growth.
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Affiliation(s)
| | - Ben Trinh
- Department of Research, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Angela Jacques
- Institute for Health Research, The University of Notre Dame, Fremantle, WA, Australia
- Curtin University, Bentley, WA, Australia
| | - Glen Lo
- Sir Charles Gairdner Hospital, Nedlands, WA, Australia.
- Diagnostic Imaging, Sir Charles Gairdner and Osborne Park Hospital Care Group, Hospital Avenue, Nedlands, WA, Australia.
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Martin-Grace J, Tomkins M, O'Reilly MW, Sherlock M. Iatrogenic adrenal insufficiency in adults. Nat Rev Endocrinol 2024; 20:209-227. [PMID: 38272995 DOI: 10.1038/s41574-023-00929-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/23/2023] [Indexed: 01/27/2024]
Abstract
Iatrogenic adrenal insufficiency (IAI) is the most common form of adrenal insufficiency in adult patients, although its overall exact prevalence remains unclear. IAI is associated with adverse clinical outcomes, including adrenal crisis, impaired quality of life and increased mortality; therefore, it is imperative that clinicians maintain a high index of suspicion in patients at risk of IAI to facilitate timely diagnosis and appropriate management. Herein, we review the major causes, clinical consequences, diagnosis and care of patients with IAI. The management of IAI, particularly glucocorticoid-induced (or tertiary) adrenal insufficiency, can be particularly challenging, and the provision of adequate glucocorticoid replacement must be balanced against minimizing the cardiometabolic effects of excess glucocorticoid exposure and optimizing recovery of the hypothalamic-pituitary-adrenal axis. We review current treatment strategies and their limitations and discuss developments in optimizing treatment of IAI. This comprehensive Review aims to aid clinicians in identifying who is at risk of IAI, how to approach screening of at-risk populations and how to treat patients with IAI, with a focus on emergency management and prevention of an adrenal crisis.
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Affiliation(s)
- Julie Martin-Grace
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Maria Tomkins
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Michael W O'Reilly
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Mark Sherlock
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland.
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland.
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7
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Elhassan YS. Insights on Adrenal Hemorrhage. Mayo Clin Proc 2024; 99:355-356. [PMID: 38432742 DOI: 10.1016/j.mayocp.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Accepted: 01/23/2024] [Indexed: 03/05/2024]
Affiliation(s)
- Yasir S Elhassan
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Endocrinology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom. https://twitter.com/Yasir_SElhassan
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Hasan E, Lamba A, Ghosh A, Kocharyan H, Al-Roubaie M, Yeisley C. Spontaneous Contralateral Adrenal Hemorrhage during Periduodenal Abscess Drain Placement. Diagnostics (Basel) 2024; 14:334. [PMID: 38337850 PMCID: PMC10855622 DOI: 10.3390/diagnostics14030334] [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: 12/25/2023] [Revised: 01/26/2024] [Accepted: 01/30/2024] [Indexed: 02/12/2024] Open
Abstract
A spontaneous adrenal hemorrhage is a rare complication occurring in the setting of interventional radiology procedures. Here, we present the case of a 73-year-old male who underwent CT-guided drainage of a periduodenal collection. During the procedure, he developed sudden onset left back pain and hypertension, which revealed a left adrenal gland hemorrhage on CT imaging. Potential mechanisms for this complication include a physiological stress response, procedure-associated hypercoagulability, and direct trauma to the adrenal gland. Moreover, an adrenal hemorrhage should be monitored closely as it can lead to severe clinical consequences requiring treatment with IV analgesics and antihypertensives.
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Affiliation(s)
- Eusha Hasan
- Department of Vascular and Interventional Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA;
| | - Ashley Lamba
- Department of Vascular and Interventional Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA;
| | - Abheek Ghosh
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland Medical Center, Baltimore, MD 21201, USA;
| | - Hakob Kocharyan
- Department of Vascular and Interventional Radiology, Moffitt Cancer Center, Tampa, FL 33612, USA; (H.K.); (M.A.-R.)
| | - Mustafa Al-Roubaie
- Department of Vascular and Interventional Radiology, Moffitt Cancer Center, Tampa, FL 33612, USA; (H.K.); (M.A.-R.)
| | - Christopher Yeisley
- Department of Vascular and Interventional Radiology, David Grant USAF Medical Center, Fairfield, CA 94535, USA;
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9
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Øksnes M, Husebye ES. Approach to the Patient: Diagnosis of Primary Adrenal Insufficiency in Adults. J Clin Endocrinol Metab 2023; 109:269-278. [PMID: 37450570 PMCID: PMC10735307 DOI: 10.1210/clinem/dgad402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/28/2023] [Accepted: 07/05/2023] [Indexed: 07/18/2023]
Affiliation(s)
- Marianne Øksnes
- Department of Clinical Science, University of Bergen, N-5021 Bergen, Norway
- Department of Medicine Haukeland, University Hospital, N-5021 Bergen, Norway
| | - Eystein S Husebye
- Department of Clinical Science, University of Bergen, N-5021 Bergen, Norway
- Department of Medicine Haukeland, University Hospital, N-5021 Bergen, Norway
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10
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Al-Rawi S, Seidahmed M, Emam SS, Othman ES. A 65-Year-Old Man with Bilateral Adrenal Hemorrhage Following Prophylaxis for Postoperative Deep Vein Thrombosis with Rivaroxaban. AMERICAN JOURNAL OF CASE REPORTS 2023; 24:e939816. [PMID: 37658601 PMCID: PMC10479204 DOI: 10.12659/ajcr.939816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 07/19/2023] [Accepted: 06/27/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND Direct oral anticoagulant (DOAC) agents, such as rivaroxaban, treat and prevent venous thrombosis. Although adrenal hemorrhage due to DOACs has previously been reported, this is a rare condition that can present as an emergency. In this case report, we present a 65-year-old man who recently had bilateral knee arthroplasty and was started on rivaroxaban 10 mg daily for deep vein thrombosis (DVT) prophylaxis following the surgery. CASE REPORT Ten days after bilateral knee arthroplasty and starting rivaroxaban, the patient presented to the Emergency Department with severe, sudden abdominal pain. Abdominal computed tomography detected significantly enlarged bilateral adrenals, with ill-defined heterogeneous density extending to the upper part of perinephric and paranephric spaces, suggesting bilateral adrenal hemorrhage. A cosyntropin stimulation test was used to confirm the suspicion of adrenal insufficiency. Cortisol levels were 66 nmol/L before stimulation and 83 nmol/L 60 min after cosyntropin administration. Hydrocortisone was started intravenously at a dose of 50 mg every 8 h. After his symptoms improved, he was discharged on oral hydrocortisone at 10 mg in the morning and 5 mg in the evening. Seven weeks after discharge, follow-up abdominal ultrasonography showed that the bilateral adrenal hemorrhage had resolved. CONCLUSIONS This case supports previous cases of adrenal hemorrhage as a rare but serious association with rivaroxaban and highlights the importance of rapid diagnosis using imaging and monitoring of patients for this possible adverse effect. Practitioners must remain vigilant when prescribing anticoagulation therapy, especially in patients who are at an increased risk for adrenal hemorrhage.
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Affiliation(s)
- Safa Al-Rawi
- Department of Pharmacy, Al Wakrah Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Mustafa Seidahmed
- Department of Internal Medicine, Al Wakrah Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Saeed Saleh Emam
- Department of Radiology, Al Wakrah Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Eman S. Othman
- Department of Cardiology, Al Wakrah Hospital, Hamad Medical Corporation, Doha, Qatar
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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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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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13
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Kumar S, Wu K, Rodrigo N, Glover A. Massive Biochemically Silent Pheochromocytoma Masquerading as Nonfunctioning Adrenocortical Cancer. JCEM CASE REPORTS 2023; 1:luad061. [PMID: 37908587 PMCID: PMC10580479 DOI: 10.1210/jcemcr/luad061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Indexed: 11/02/2023]
Abstract
Pheochromocytomas are rare catecholamine-secreting neuroendocrine tumors of the adrenal medulla chromaffin cells, usually associated with features of catecholamine excess. Clinically and biochemically silent pheochromocytoma without adrenergic symptoms or elevated catecholamine concentrations are rare. A 71-year-old female presented with acute right flank pain with abdominal computed tomography (CT) scan revealing a hemorrhagic right adrenal mass. She had no preceding adrenergic symptoms, and normal serum electrolytes, on a background of well-controlled hypertension on amlodipine monotherapy. After conservative management and discharge, an outpatient CT adrenal scan confirmed an 88 × 64 mm right adrenal mass demonstrating intense avidity (maximum standardized uptake value, 20.2) on fluorodeoxyglucose F 18-positron emission tomography (FDG-PET)/CT scan. Biochemical screening supported a nonfunctional adrenal lesion with normal-range plasma normetanephrines and metanephrines. She underwent a right adrenalectomy for presumed nonfunctioning adrenocortical cancer; however, histopathology demonstrated a 120-mm pheochromocytoma. Succinate dehydrogenase subunit B (SDHB) and fumarate hydratase (FH) staining were retained; however, weakly positive 2SC staining raised concerns for FH-deficient pheochromocytoma. Germline DNA sequencing was negative for pathogenic RET, VHL, SDHB, SDHD, or FH variants. Tumor cells stained positive for tyrosine hydroxylase and negative for dopamine β hydroxylase. Four months postoperatively, progress FDG-PET/CT scan demonstrated no focal avidity. Massive biochemically silent pheochromocytomas are exceedingly rare, and we discuss various mechanisms that may predispose patients to this phenomenon.
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Affiliation(s)
- Shejil Kumar
- Department of Diabetes, Endocrinology & Metabolism, Royal North Shore Hospital, Sydney, NSW 2065, Australia
| | - Katherine Wu
- Department of Diabetes, Endocrinology & Metabolism, Royal North Shore Hospital, Sydney, NSW 2065, Australia
| | - Natassia Rodrigo
- Department of Diabetes, Endocrinology & Metabolism, Royal North Shore Hospital, Sydney, NSW 2065, Australia
- Northern Sydney Clinical School, Faculty of Medicine, University of Sydney, Sydney, NSW 2065, Australia
| | - Anthony Glover
- Endocrine Surgical Unit, Royal North Shore Hospital & Northern Clinical School, Sydney, Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2065, Australia
- The Kinghorn Cancer Centre, Garvan Institute of Medical Research, St. Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Darlinghurst, NSW 2010, Australia
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Cuthbertson DJ, Alam U, Davison AS, Belfield J, Shore SL, Vinjamuri S. Investigation and assessment of adrenal incidentalomas. Clin Med (Lond) 2023; 23:135-140. [PMID: 36958837 PMCID: PMC11046519 DOI: 10.7861/clinmed.2023-0042] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
With the increasing volume of diagnostic imaging undertaken in an ageing population, adrenal incidentalomas (AIs) are increasingly commonly seen. These masses are most likely to be benign, but a small proportion may be malignant. Similarly, they are usually non-functional, but ∼14% are functional, ie hormone-secreting tumours. Clinical, biochemical and radiological assessment is mandated to stratify patients into those requiring radiological surveillance, medical management or surgical intervention or who can be discharged. Mass characteristics on cross-sectional (CT/MRI) imaging influence the need for radiological surveillance. Functional tumours where excess cortisol, aldosterone or catecholamine are secreted should be excluded, with mild autonomous cortisol secretion (MACS) and primary aldosteronism (PA) as the two most common functional states. MACS and PA are associated with an increased risk of cardiometabolic disease (eg hypertension, type 2 diabetes) and cardiovascular morbidity/mortality (eg coronary heart disease). Multidisciplinary management is critical for selected cases; the majority of adrenal incidentalomas only require a single assessment.
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Affiliation(s)
- Daniel J Cuthbertson
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK and professor of medicine, University of Liverpool, Liverpool, UK
| | - Uazman Alam
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK and senior clinical lecturer in medicine, University of Liverpool, Liverpool, UK
| | - Andrew S Davison
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Jane Belfield
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Susannah L Shore
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Sobhan Vinjamuri
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
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