Spontaneous Adrenal Hemorrhage with Mild Hypoadrenalism in a Patient Anticoagulated with Apixaban for Antiphospholipid Syndrome: A Case Report and Literature Review

Table 1

Case reports of patients with adrenal hemorrhage while on anticoagulation for APLS.

Reference	Comuth et al. [2]	Lavoipierre [3]	Arosemena et al. [4]	Sanford et al. [5]	Bakhsh et al. [6]	DiCenso et al. [7]	Aneke and Gunendran [8]	Godfrey et al. [9]
Gender	Female	Male	Male	Male	Female	Male	Female	Female
Age (years)	63	47	46	42	40	46	53	68
Triple positive	Yes	Yes	NA	NA	NA	NA	NA	NA
Prior warfarin use	No	No	No	Yes	No	Yes	Current	Current
Type of DOAC	Rivaroxaban	Apixaban	Rivaroxaban	Apixaban	Rivaroxaban	Rivaroxaban	Warfarin	Warfarin
Duration of AC prior to admission	5 months	2 months	Few months	1 month	2 weeks	Unknown	7 years	Unknown
Clinical manifestations	LUQ abdominal pain, vomiting	Abdominal pain, livedo reticularis	Abdominal pain, nausea, weight loss	Fever, right flank pain	Severe RUQ pain, nausea	Abdominal pain, syncope	Nausea, vomiting, fever, rigors, R flank pain	Bilateral loin pain, vomiting, fever, confusion
Laboratory findings	K of 4.2 mmol/L and Na of 137 mmol/L		Na of 121 mmol/L, K of 5.4 mmol/L	NA	Renal function test reported normal	Na of 121 mmol/L, K of 5.5 mmol/L, random cortisol of 0.8 mcg/dL (22 nmol/L)	Na of 122, cortisol of 1.4 mcg/dL (40 nmol/L)	Na of 132, cortisol of 1.7 mcg/dL (48 nmol/L)
CT findings	Dilatation of both adrenal glands	Bilateral adrenal hematomas	Bilateral adrenal hemorrhage	Right-sided adrenal hemorrhage	Enlargement of the right adrenal gland	Thickening of the adrenal glands	Bilateral adrenal hemorrhage	Bilateral heterogenous adrenal pathology
MRI findings	Unknown	Unknown	T1 signal in the region of bilateral adrenal glands	Unknown	Unknown	T1 hyper-intensity of the bilateral adrenal glands	No	No
ACTH stimulation	Positive	Positive	NA	NA	NA	NA	NA	NA
Treatment	Methylpred 40 mg IV-switched to HC (dose/duration unknown)	HC + fludrocortisone	HC 50 mg q 6 hr + fludrocortisone 0.1 mg daily	Unknown	Methylpred 1.5 mg/kg	HC 50 mg IV every 8 hours	IV HC	IV HC 100 mg q 6 h->switched to oral HC + fludrocortisone
Medication upon discharge	Unknown	HC + fludrocortisone	HC 15 mg in AM and 10 mg in PM fludro 0.1 mg daily	Unknown	Unknown	HC + fludrocortisone	Oral HC-reducing doses to reach target dose: 10 mg AM, 5 mg noon, 5 mg night	HC + fludrocortisone
Anticoagulation upon discharge	Dalteparin 15.000 IE daily-switched to warfarin after a month (unknown target INR)	Warfarin	Warfarin (unknown target INR)	Warfarin (target INR 2.5–3.5)	Warfarin (target INR 2–2.5)	Unknown	Fondaparinux-switched back to warfarin after 5 days	Unknown

N/A: not applicable, DOAC: direct oral anticoagulant, Na: sodium, K: potassium, LUQ: left upper quadrant, Methylpred: methylprednisolone, HC: hydrocortisone, and IV: intravenous.