Bilateral adrenal haemorrhage secondary to rivaroxaban in a patient with antiphospholipid syndrome

Arosemena, Marilyn; Rodríguez, Andrés; Ediriweera, Hasini

doi:10.1136/bcr-2020-234947

Cited by 9 publications

(7 citation statements)

References 7 publications

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“…At the time of this writing, we found 8 cases [2][3][4][5][6][7][8][9] of AH in patients with APLS on anticoagulation (Table 1). Six out of 8 patients were on DOACs.…”

Section: Resultsmentioning

confidence: 99%

Spontaneous Adrenal Hemorrhage with Mild Hypoadrenalism in a Patient Anticoagulated with Apixaban for Antiphospholipid Syndrome: A Case Report and Literature Review

Tan

Shukla

et al. 2022

Case Reports in Endocrinology

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Background. Adrenal hemorrhage (AH) is a serious endocrine complication of antiphospholipid syndrome (APLS). Case Presentation. We report a 45-year-old man who presented with several deep venous thromboses and was initially treated with apixaban, who later developed bilateral AH. Laboratory findings were consistent with cortisol deficiency yet preserved aldosterone physiology. He was diagnosed with APLS and treated with warfarin. After 8 months of follow-up, he remained on cortisol replacement with no evidence of recovery. We reviewed PubMed/MEDLINE indexed articles from 1950 to 2022 for cases of AH in APLS patients on anticoagulation. Six cases of patients on direct oral anticoagulants (DOACs) were reported. Discussion. The unique vasculature of the adrenal glands creates a “functional vascular dam” in the zona reticularis, which is susceptible to thrombosis in situ and hemorrhage. DOACs may further increase the risk of AH. Conclusion. Depending on the degree of adrenal involvement in AH, patients can present with partial or complete primary adrenal insufficiency. More data are needed to characterize adrenal function after AH, and the safety of DOAC versus warfarin in patients with APLS warrants further studies.

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“…At the time of this writing, we found 8 cases [2][3][4][5][6][7][8][9] of AH in patients with APLS on anticoagulation (Table 1). Six out of 8 patients were on DOACs.…”

Section: Resultsmentioning

confidence: 99%

Spontaneous Adrenal Hemorrhage with Mild Hypoadrenalism in a Patient Anticoagulated with Apixaban for Antiphospholipid Syndrome: A Case Report and Literature Review

Tan

Shukla

et al. 2022

Case Reports in Endocrinology

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“…7 Diagnosis of adrenal crisis is difficult because of nonspecific symptoms such as hypotension, hypovolemia, nausea, abdominal pain, fatigue, among others, for which paraclinical tests such as sodium, potassium, glucose, and serum cortisol must be performed. 8 Serum cortisol at 8 am is clinically useful to rule out adrenal insufficiency. Levels above 20 mg/ dL (550 nmol/L) make the diagnosis of adrenal insufficiency unlikely, whereas a cortisol level of less than 5 mg/dL supports the diagnosis.…”

Section: Discussionmentioning

confidence: 99%

Adrenal crisis as initial manifestation of bilateral adrenal hemorrhage due to antiphospholipid syndrome: A case report

Diana

Daniela

et al. 2023

SAGE Open Medical Case Reports

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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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“…Because routine coagulation tests cannot be used to determine the degree of anticoagulation in individuals receiving a DOAC, managing bleeding can be challenging [ 12 ].To the best of our knowledge, only five cases of AH have been reported as a result of the use of the latest anticoagulant drugs (Table 3 ). Four with the use of rivaroxaban [ 10 , 35 – 37 ], and only one through the use of apixaban [ 22 ] prophylactic treatment. However, all of the evaluated cases demonstrated AI as a result of bilateral AH.…”

Section: Discussionmentioning

confidence: 99%

“…This may result in hypocortisolemia due to decreased cortical lipids, as demonstrated in a case presented by B.Ly [ 37 ], a case of unilateral AH with confirmed AI in the laboratory test. Two of these four were under prophylactic anticoagulation following knee surgery in the patients [ 10 , 37 ], and the rest were due to APLS [ 35 , 36 ]. Our second case was similar to the mentioned cases because AH also occurred following rivaroxaban treatment after femur fixation surgery.…”

Section: Discussionmentioning

confidence: 99%

“…NM = not mentioned, APLS = antiphospholipid syndrome, IJVT=internal jugular vein thrombosis, AH = adrenal hemorrhage, AI = adrenal insufficiency No Author, [reference] Age/Gender Presentation Anticoagulant drugs Anticoagulant drugs dosage Reason to get Anticoagulant prophylaxis Laterality of AH Presence of Addison Disease as a medical background AI secondary to the AH 1 W. Comuth(2017) [ 36 ] 63/Female Abdominal pain Rivaroxaban (Xarelto) 20 mg daily APLS Bilateral - + 2 Z. Sanford(2019) [ 22 ] 42/Male Acute onset severe right flank pain Apixaban (Eliquis) NM APLS Unilateral - - 3 B. A. Ly(2019) [ 37 ] 61/Male Nausea and vomiting Rivaroxaban 10 mg daily Knee Surgery Unilateral - - 4 M. Alidoost(2019) [ 10 ] 68/Female Severe acute onset abdominal pain Rivaroxaban 10 mg daily Knee Surgery Bilateral - + 5 M. A. Arosemena(2020) [ 35 ] 46 / Male...…”

Section: Discussionmentioning

confidence: 99%

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Adrenal hemorrhage following direct oral anticoagulant (DOAC) therapy: two case reports and literature review

et al. 2022

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Background Adrenal hemorrhage (AH) is a rare condition that can result in a life-threatening medical emergency. This medical condition could be caused by several underlying factors, one of which is the use of anticoagulants. As far as we are aware, direct oral anticoagulant (DOAC) agents are a rare but possible cause of AH. Case presentation Herein, we described two cases of AH due to DOACs. The first case was a 35-year-old Iranian woman with a past medical history of Hashimoto thyroiditis who was being treated with apixaban due to the previous thrombosis. Her first symptoms of AH (November 2021) were strangely similar to symptoms of autoimmune Addison disease (AAD) which led to a confirmed diagnosis of autoimmune polyendocrine syndrome type 2 (APS-2). An abdominal MRI revealed an oval shape well-encapsulated cystic mass with a diameter of 20 × 14 mm with a thick and low signal intensity rim in the left adrenal gland, highly suggestive of sub-acute left-sided AH. Our second case was an 89-year-old Iranian woman who had been admitted to the hospital (August 2021) with low blood pressure and disorientation. At the beginning of her admission, the evaluation showed hyponatremia, and further evaluations confirmed adrenal insufficiency (AI). The patient reported rivaroxaban usage for deep vein thrombosis prophylaxis after femur fixation surgery. Her abdominal CT scans showed bilateral adrenal masses highly suggestive of AH. Her follow-up examination showed persistent AI after three months. Conclusion Given the history of our cases, physicians should be aware of AH in patients receiving DOACs, particularly in elderly patients who are at high risk of bleeding. It is also worth noting that AH can occur in any patient with any medical history and history of DOAC use, which is why patients must be closely monitored.

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Bilateral adrenal haemorrhage secondary to rivaroxaban in a patient with antiphospholipid syndrome

Cited by 9 publications

References 7 publications

Spontaneous Adrenal Hemorrhage with Mild Hypoadrenalism in a Patient Anticoagulated with Apixaban for Antiphospholipid Syndrome: A Case Report and Literature Review

Spontaneous Adrenal Hemorrhage with Mild Hypoadrenalism in a Patient Anticoagulated with Apixaban for Antiphospholipid Syndrome: A Case Report and Literature Review

Adrenal crisis as initial manifestation of bilateral adrenal hemorrhage due to antiphospholipid syndrome: A case report

Adrenal hemorrhage following direct oral anticoagulant (DOAC) therapy: two case reports and literature review

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