Endocrine Abstracts

Background: Antiphospholipid syndrome (APS) is characterized by venous or arterial thrombosis and/or an adverse pregnancy outcome in the presence of persistent laboratory evidence of antiphospholipid antibodies. Loss of adrenal function due to bilateral adrenal vein thrombosis, resulting in hemorrhagic infarction, may occur in association with APS.

Case presentation: We present the case of a 45-year-old woman with APS diagnosis since she was 37, with history of multiple thrombotic events (deep vein thrombosis, sigmoid sinus thrombosis, spontaneous abortion, adrenal hematoma and pulmonary embolism). She was hospitalized for adrenal hematoma under anticoagulant therapy with warfarin. The basal adrenal function tests revealed morning serum cortisol 0.7 μg/dl (reference range 3.7–19.4) and ACTH 345 pg/ml (5–46). Abdominal CT showed nodular lesion with 55 HU density (29×27 mm) suggestive of adrenal hematoma in the left adrenal gland; right gland is thickenned. Adrenal insufficiency was associated with both hematoma in the left adrenal gland and thrombosis in the right gland. The patient was discharged under corticosteroid treatment and low molecule weight heparin (LMWH). After being discharged, warfarin was started again and she was admitted in the emergency department with dyspnea and pleuritic chest pain. Initial analytical study revealed INR (2.26), hypoxemia (PO2:64 mm/Hg) and hypocapnia (32 mm/Hg). She was restarted on therapy with LMWH. Further study showed deep vein thrombosis in right lower extremity. The patient was discharged after vena cava filter replacement.

Discussion: The recurrence rate of thrombotic events among patients with APS is highly variable among studies, with an annual recurrent thrombosis risk ranging from 5 to 12%. However adrenal involvement has been reported in 13% of cases of catastrophic APS. In patients with antiphospholipid antibody syndrome, adrenal insufficiency is often seen with bilateral adrenal thrombosis, although rarely in some patients an adrenal gland hemorrhage may occur with other adrenal gland hematomas.