Endocrine Abstracts

Case History: We report the case of a 23-year-old woman who developed adrenal insufficiency secondary to bilateral adrenal haemorrhage in the context of vaccine-induced thrombosis and thrombocytopenia (VITT). She presented with breathlessness and chest pain eight days after receiving her first dose of the adenoviral vector-based ChAdOx1 vaccine. Over the course of a week, she developed fulminant VITT. Her only comorbidity was obesity, with BMI of 35 kg/m2.

Investigations: Investigations showed low platelet count of 43 x109/l and raised D-Dimers >100,000 ng/ml. CT pulmonary angiogram showed multiple lobar and segmental pulmonary emboli, requiring anticoagulation. Additional cross-sectional imaging performed sixteen days post-vaccination due to acute clinical deterioration with refractory hypotension, revealed bilateral adrenal haemorrhage, non-occlusive splenic vein thrombosis and right ventricular thrombosis. Cortisol level was <25 nmol/l, confirming adrenal insufficiency. Anti-platelet factor 4 antibodies were detected confirming definite VITT in accordance with the UK diagnostic criteria.

Results and treatment: The patient received intravenous hydrocortisone replacement and was aggressively resuscitated with intravenous fluids promptly. Furthermore, she required anticoagulation, plasmapheresis and immunosuppression. After 4 weeks in hospital, she recovered fully and was discharged on warfarin, hydrocortisone and fludrocortisone replacement. Short synacthen tests (SST) at 3 and 9 months after presentation demonstrated a flat response (0” cortisol 37 nmol/l and 30” cortisol 43 nmol/l; at 9 months 0” 41 nmol/l and 30” 53 nmol/l) demonstrating ongoing adrenal insufficiency. Magnetic-resonance-imaging of the adrenal glands showed resolving adrenal haemorrhage. She is still receiving hydrocortisone 10/5/5 mg and fludrocortisone 50 mg daily

Conclusions and points for discussions: Adrenal insufficiency secondary to bilateral adrenal haemorrhage should be suspected in patients with VITT and treated promptly. Adrenal vein haemorrhage can occur as the initial presentation of VITT or even days to weeks later after the development of thrombosis in other more classic sites. Completion of vaccination schedule against SARS-CoV-2 using an mRNA-based vaccine should be recommended to patients post-VITT, as mRNA-based vaccines have not been associated with VITT, but confer protection against SARS-CoV-2. There is paucity of data regarding the potential for recovery of adrenal function after bilateral adrenal haemorrhage in the context of VITT and thus more studies are needed to inform clinical practice. Finally, this case highlights the need for disease registries for rare conditions, such as VITT. This is crucial as direct cooperation and sharing of information by clinicians might enable quicker identification of disease patterns than would have been possible via established reporting tools of adverse events.