Searchable abstracts of presentations at key conferences in endocrinology
Endocrine Abstracts (2011) 25 P63

SFEBES2011 Poster Presentations Clinical biochemistry (82 abstracts)

Adrenal haemorrhage associated with therapeutic Clexane and subtherapeutic warfarin

Panagiota Anna Chousou , Mansour Seidahmad , Firas Haddadin & Adrian Jennings

Diabetes and Endocrinology Centre, Queen Elizabeth Hospital, King’s Lynn, Norfolk, UK.

Adrenal haemorrhage is rarely associated with anticoagulation according to a large American series. We present 2 cases in whom there was no evidence of over anticoagulation, both of whom developed a degree of hypoadrenalism.

Case 1: A 72-year-old-male presented with severe non-pleuritic left flank pain. He had been seen the previous day with possible deep venous thrombosis (DVT) and had received a single dose of enoxaparin (1.5 mg/kg). He was tender in the left flank. Investigations confirmed pulmonary embolism and DVT, so he continued therapeutic enoxaparin. He became progressively hypotensive, hyponatraemic and hyperkalaemic 3 days after admission. A short Synacthen test confirmed hypoadrenalism (peak serum cortisol 85 nmol/l). Adrenal CT showed bilateral adrenal enlargement, compatible with haemorrhage. Extensive investigations for malignancy were negative and repeat CT 3 months later showed normal adrenals.

Case 2: A 64-year-old-male presented with sudden vertigo, right loin pain and vomiting. He was taking warfarin for apical thrombus following a myocardial infarction. He was tender in the right renal angle, but haemodynamically stable. His INR was 1.8 and recent results did not show over-anticoagulation. CT scan showed bilateral adrenal enlargement and features consistent with adrenal haemorrhage, especially on the right. Investigations for underlying neoplasia were negative. Short Synacthen testing showed a suboptimal response (peak serum cortisol 524 nmol/l). Eleven months after discharge a repeat CT scan was normal apart from minor thickening in the left adrenal gland.

Adrenal haemorrhage was associated with anticoagulation in only 2% of 141 cases in a large American series collected over 25 years (1972–97). More recently there has been increasing use of anticoagulation so the incidence may have increased. The presentation can be non-specific so it is important to consider this diagnosis in patients with abdominal or flank pain and those with any features of hypoadrenalism.

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