Abstract #1174376: Atraumatic Adrenal hemorrhage in a patient anticoagulated with Apixaban

Abstract

Adrenal hemorrhage is an unusual complication with anticoagulation. Case reports have been mostly limited to patients on unfractionated or low-molecular weight heparin. We present a case of Apixaban induced adrenal hemorrhage. The patient is a 48-year-old man with hypertension who had DVT and PE from immobilization. He was started on Apixaban for VTE prophylaxis. After 4 days on Apixaban he presented to the ED with nausea, fatigue, and constipation but was hemodynamically stable. Labs were okay, except WBC of 11. CT Abdomen showed right adrenal stranding with features of pyelonephritis and cystitis. He was discharged home from ED on antibiotics and laxatives. He presented with nausea, vomiting, diarrhea, and an episode of a tonic-clonic seizure 10 days later. He was found to be hypotensive and tachycardic. Labs showed Na 103 mmol/L, K 6.1mmol/L, Creatinine 1.2mg/dl, CO2 11meq/L, Anion gap 13, PM Cortisol of 5.40mcg/d. He was admitted to the ICU for further management. The electrolyte imbalance was attributed to diarrhea and treated with ½ NS, NaHCO3 drip and Tolvaptan. He improved clinically with the correction of electrolyte abnormalities. Apixaban was switched to Rivaroxaban on discharge. At follow up with PCP, he was feeling better, but not yet at his baseline. After a 3-month course of Rivaroxaban he was transitioned to Aspirin. The antihypertensive therapy was discontinued as he developed orthostatic hypotension with normal BP. Over time, he had shortness of breath, fatigue, hyperpigmentation, and weight loss of about 20 kg. Repeat labs were, Na 131mmol/L, K 6.1mmol/L, Creatinine 1.6 mg/dl, Cortisol AM 1.7 mcg/dL, Aldosterone < 1ng/dl, Glucose 82. On the Cosyntropin stimulation test ACTH was > 2000, AM Cortisol was 1.4 μg/dL and Cortisol at 60 minutes was 1.5 μg/dL. He was confirmed to have Adrenal insufficiency and PO Hydrocortisone 15 mg in AM and 5 mg in the afternoon, Fludrocortisone 0.05 mg daily were initiated with marked improvement of the symptoms. A CT abdomen one year later, revealed resolution of the periadrenal stranding and a nodular opacity in the right adrenal gland. Diagnosis of adrenal hemorrhage can be neglected, due to nonspecific presentation. Our patient presented within 4 days of starting Apixaban. Although CT abdomen at that time was suggestive of an adrenal hemorrhage, the mentioned inflammatory changes were incorrectly attributed to the possible pyelonephritis. These changes have also been reported to precede adrenal hemorrhage. As the use of NOAC increases, physicians must be aware of adverse reactions in the appropriate clinical setting and treat accordingly.