Rivaroxaban Related Bilateral Adrenal Hemorrhage: A Rare Complications of Direct Oral Anticoagulants – A Case Reports

Abstract

Patient: Female, 68Final Diagnosis: Adrenal hemorrhageSymptoms: Abdominal and/or epigastric painMedication: RivaroxavanClinical Procedure: —Specialty: General and Internal MedicineObjective:Rare diseaseBackground:Adrenal hemorrhage is an uncommon and under-recognized disorder with a wide array of etiologies ranging from pregnancy to septic shock. It is one of the complications of anticoagulation therapy, including direct anticoagulant medications.Case Report:Here, we present a case of a 68-year-old female with recent right knee arthroplasty who was on rivaroxaban for deep vein thrombosis (DVT) prophylaxis presented to the emergency department (ED) for severe acute onset abdominal pain, computed tomography (CT) of abdomen and pelvis revealed possible left adrenal hemorrhage that was confirmed with magnetic resonance imaging (MRI). On repeat CT, her unilateral adrenal hemorrhage converted to a bilateral adrenal hemorrhage (BAH) and, as a result, the patient developed adrenal insufficiency.Conclusions:An undiagnosed and untreated adrenal hemorrhage can have catastrophic consequences, leading to adrenal insufficiency with potential shock and death. Therefore, it is important for clinicians to have an increased awareness and knowledge about adrenal hemorrhage.

A Rare Case of Waterhouse-Friderichsen Syndrome Without Purpura Secondary to Haemophilus Influenzae

“…The WFS is a rare disease and mostly fatal, and it occurs acutely in most cases [3][4][5][6][7][8][9]. It is mainly diagnosed at post-mortem; thus, the need for a high index of suspicion and urgent intervention is required.…”

“…It is mainly diagnosed at post-mortem; thus, the need for a high index of suspicion and urgent intervention is required. Neisseria meningitidis is isolated in more than 80% of WFS cases, other bacteria are Haemophilus influenzae and Pseudomonas aeruginosa, as seen in this case, Streptococcus pneumoniae, Staphylococcus aureus, group A Streptococcus, Neisseria gonorrhoeae, Proteus mirabilis, Klebsiella, and Legionella [4][5][6][7][8][9][10]. It is essential to know that bilateral adrenal haemorrhage on its own has other causes besides sepsis.…”

“…It could have been worsened by direct oral anticoagulation as the patient was on apixaban and INR on admission was 3. The cause is unknown sometimes, as evidenced by documented cases of idiopathic bilateral adrenal haemorrhage [5][6][7][8][9][10][11].…”

“…Bilateral adrenal haemorrhage presents with vague symptoms, and this led to late diagnosis in this case [4][5][6][7][8][9][10][11]. It was diagnosed 10 days after admission as an incidental finding on CT thorax.…”

“…Late diagnosis is because this patient had septic shock due to pneumonia; severe sepsis and inadequate fluid intake explained the low blood pressure. The diagnosis is so challenging that it is often diagnosed at post-mortem [7][8][9][10][11][12]. Symptoms of adrenal haemorrhage include abdominal, back, and flank pain.…”