[Hematoma of the adrenal glands and heparin]

Prise en charge des hématomes post-traumatiques isolés de la surrénale

We report three cases of isolated adrenal haematoma diagnosed at admission to the Emergency Department. Post-traumatic adrenal haematoma have been observed in 2% of patients with abdominal injury and can be life threatening in cases of bilateral haemorrhage with risk of acute adrenocortical insufficiency. Diagnosis remains difficult due to absence of clinical and biological specific parameters. Therefore, abdominal CT examination should be the gold standard in management of abdominal trauma patients.

[Adrenal gland hematoma due to rupture of myelolipoma. A case report]

The myelolipoma is a benign tumour of the adrenal cortex, non functioning and normally asymptomatic, which can be diagnosed by chance in imaging test. Rupture and bleeding of the myelolipoma is an infrequent complication, which can conclude with the formation of a haematoma or, less usually, result in a massive retroperitoneal haemorrhage. The compression of adjacent structures by retroperitoneal haematomas with adrenal origin is a possible but not frequent eventuality. Indications for surgery of haematoma retroperitoneal continue to be, nowadays, a difficult and controversial decision, because the problem is normally resolved with conservative treatment and a watchful approach. We are presented with a 69 year old male who came to casualty with abdominal pain of 7 days duration, whose origin coincided with a light blow. The image test revealed the existence of a retroperitoneal haematoma with adrenal gland origin of 16 cm, with active bleeding, which was displaced and compressed the cava vein. We have only found one case, in the literature, of compression of the cava vein coused by adrenal gland haematoma. In the case under our observation, urgent surgery was needed.

MRI diagnosis of bilateral adrenal vein thrombosis

We report a case of bilateral adrenal vein thrombosis in an adult female who had a history of breast cancer. The patient does not have clinical, serological or imaging evidence of metastatic disease 14 months from the initial diagnosis. Adrenal vein thrombosis is a rare entity. There have been no previous reports specifically stating an association between adrenal vein thrombosis and hypercoaguability, but there are many cases in the literature documenting venous thrombosis elsewhere within the body in patients with hypercoaguable states. Laboratory testing performed to exclude a hypercoaguable state, revealed heterozygosity for the Factor V Leiden mutation/activated protein C resistance and elevated factor VIII levels [3660 IU l(-1) (<1500)]. This is the first reported case of bilateral metachronous adrenal vein thrombosis in which MRI established the diagnosis.

[Sheehan's syndrome: a recurrent obstetrical complication]

Case report of a 25-year-old primigravida who sustained a necrosis of the anterior pituitary gland after a haemorrhagic Caesarean section. The diagnosis was delayed, as the early symptoms (apathy, anorexia, nausea, orthostatic hypotension and hypoglycaemia) were imputed to more usual causes.

Heparin-related thrombocytopenia and adrenal hemorrhagic necrosis following aortic surgery

Adrenal hemorrhagic necrosis is one of several possible complications of heparin-related thrombocytopenia. We report a case in which adrenal hemorrhagic necrosis developed after aortofemoral bypass. This serious complication remains difficult to diagnose in the absence of a high index of suspicion. A routine search for this condition in the setting of heparin-related thrombocytopenia is essential since a favorable outcome is dependent on early diagnosis.

[Spontaneous retroperitoneal hematoma: a rare cause of hemorrhagic shock]

A spontaneous retroperitoneal haematoma is an uncommon cause of haemorrhagic shock. We report a case of spontaneous rupture of a renal angiomyolipoma resulting in haemorrhagic shock in a 52-year-old woman. The renal tumor was recognized by sonography and diagnosed by CT-scan. Renal angiography was performed, but embolization was not successful. During the surgical procedure, nephrectomy was required because of persistent bleeding, related to disseminated intravascular coagulation. Outcome was uneventful. Diagnosis and treatment of renal angiomyolipoma are discussed. The Lenk's triad, consisting of acute lumbar pain, symptoms of internal bleeding and lumbar tumefaction, is the usual clinical picture of retroperitoneal haemorrhage. The kidney is the most frequent cause and renal angiomyolipoma is the most frequent benign tumor. Renal angiomyolipoma is either isolated or associated with tuberous sclerosis in up to 20 per cent of patients. Diagnosis is suggested by sonography and confirmed by CT-scan. Renal angiography, performed in haemodynamically stable patients, shows the origin of bleeding and allows embolization. Considering the frequent bilaterality of angiomyolipoma, surgery should be as conservative as possible in order to preserve renal function.

Heparin-associated thrombocytopenia syndrome: an underestimated etiology of adrenal hemorrhage

A 74-year-old man developed bilateral arterial thrombosis of the lower limbs related to heparin-associated thrombocytopenia syndrome (HATS). On day 4 after thrombectomy of both limbs, abdominal pain, fever, hypotension, abdominal tenderness appeared. Acute acalculous cholecystitis was suspected and cholecystectomy was carried out although the gallbladder was not imflamed. Later on, hyponatremia in addition to the aforesaid signs suggested the diagnosis of adrenal insufficiency. Diagnosis was confirmed by low cortisol and aldosterone plasma concentration and by CT scan, which showen two enlarged adrenal glands. HATS might explain two unexpected facts: occurrence of adrenal hemorrhage during heparin therapy with coagulation tests within the therapeutic range and paradoxical thrombosis in the central vein of adrenal gland. HATS must be regarded as one cause of adrenal hemorrhage necrosis.

Acute adrenal insufficiency secondary to heparin-induced thrombocytopenia-thrombosis syndrome

OBJECTIVE

To present a case of acute adrenal insufficiency secondary to heparin-induced thrombocytopenia-thrombosis syndrome (HITTS), an important though rare complication of heparin therapy.

CLINICAL FEATURES

A 69-year-old woman developed HITTS secondary to low dose heparin administered subcutaneously as prophylaxis against deep venous thrombosis. This followed a revision of a knee replacement. The first manifestation of HITTS was the development of pulmonary emboli in the setting of a falling platelet count. Bilateral adrenal haemorrhages complicated her course resulting in acute adrenal insufficiency. Non-specific symptoms dominated the clinical picture, with fever, nausea, abdominal pain and vomiting. Symptomatic postural hypotension was noted later in the course of her illness.

INTERVENTION AND OUTCOME

The diagnosis of adrenal insufficiency was confirmed by short Synacthen test plus computed tomographic scanning which demonstrated bilateral adrenal haemorrhages. Steroid replacement resulted in rapid clinical improvement.

CONCLUSIONS

This case demonstrates one of the life threatening complications that may occur with heparin even in prophylactic doses. Regular platelet counts are essential to detect heparin-induced thrombocytopenia at an early stage.