Adrenal Insufficiency Due to Bilateral Adrenal Hemorrhage in Anti-Phospholipid Syndrome (APLS) and Systemic Lupus Erythematosus (SLE)

Presentation Number: SAT-0771
Date of Presentation: June 21st, 2014

Anis Rehman*1, Michael Dominic Morocco2 and Vidhya Sabapathy3
1Akron General Medical Center, Cleveland Clinic Affiliate, Akron, OH, 2Endocrine Associates, Akron, OH, 3NorthEast Ohio Medical Univesity, Akron, OH

Abstract

Introduction:

Anti-Phospholipid Syndrome (APLS) is a frequent accompaniment with Systemic Lupus Erythematosus (SLE). The condition predisposes to thrombosis, however adrenal hemorrhage in such population is exceptionally rare.

Case Report:

A 57-year-old Caucasian female, presented to the emergency room with altered mental status, shortness of breath and decreased urine output for 48 hours. Vital signs revealed hypotension (blood pressure 53/30), tachycardia (pulse 110/minute), and a temperature of  37.0 (°C).  Laboratory investigations were significant for decreased  sodium 125 mEq/L potassium 3.1 mEq/L, blood glucose (serum sugar 46 mg/dL) and elevated creatinine (Cr 5.23 mg/dL). Chest x-ray showed diffuse bilateral lower lobe infiltrates and VBGS were: pH 7.34, pCO2 43.2 mmHg, pO2 32.7 mmHg, HCO3- 22.9mEq/L, O2% Sat Venous 52.9%.

Thus a preliminary diagnosis of sepsis with acute respiratory failure secondary to pneumonia and acute kidney injury was made and the patient was intubated and shifted to the ICU. CT scan of abdomen and pelvis (without contrast) performed in ICU showed a 2.4 x 4cm right and 3 x 4 cm left adrenal gland abnormality that was consistent with adrenal hemorrhage. Patient had been on warfarin 5 mg daily for APLS with an INR being subtheraputic 1.33, she was switched to heparin drip at 20 units/kg/hour in the ICU. An endocrinology consultation was obtained and the dose of hydrocortisone 50 mg q24h was continued.

The patient initially received one time dose of Piperacillin/tazobactam 3.375 g and vancomycin 1g q12h, however after Infectious Disease consultation, the antibiotics were switched to ciprofloxacin 200 mg q12h IV and meropenum 0.5 gm q24h for highly resistant gram negative rod coverage.

Patient gradually responded over a period of 2-3 days. The patient was extubated on day 5 and was discharged on physiologic cortisol replacement, with hydrocortisone 20 mg qAM and 10 mg qPM.

Discussion:

Adrenal hemorrhage is a relatively uncommon condition with a non-specific presentation (typically flank, back or abdominal pain), but can also present through cardiovascular sequel. Without prompt management, the condition it could lead to adrenal crisis, shock and death with an overall mortality rate of 15%.

 Our case illustrates several risk factors for adrenal insufficiency such as sepsis, APLS and use of anti-coagulant therapy. Adrenal hemorrhage is a life threatening condition warranting prompt diagnosis and therapy. Clinicians should maintain a high index of suspicion while managing cases of hypotension in the setting of risk factors. A timely CT scan of abdomen and steroid administration could be life saving in such cases.

 

Nothing to Disclose: AR, MDM, VS