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Ornaghi S, Fernicola F, Marelli E, Perotti M, Di Gennaro F, Cameroni I, Mariani EM, Pincelli AI, Colciago E, Cetin I, Vergani P. Acute spontaneous non-hemorrhagic adrenal infarction in pregnancy: case-report and literature review. Gynecol Endocrinol 2023; 39:2234492. [PMID: 37486308 DOI: 10.1080/09513590.2023.2234492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 07/05/2023] [Indexed: 07/25/2023] Open
Abstract
Unilateral non-hemorrhagic adrenal infarction (NHAI) is a very uncommon cause of acute abdomen in pregnancy. Diagnosis is highly challenging due to its rarity, heterogeneity of clinical presentation, and inconclusiveness of the initial workup. Timely recognition is pivotal to ensuring optimal outcomes. Here we describe a case of spontaneous unilateral NHAI diagnosed in a singleton pregnant woman at 32 weeks' gestation at our centre and provide the findings of an extensive literature review on the topic. We identified 22 articles describing 31 NHAI cases in 30 obstetric patients: NHAI occurs more frequently on the right side and in the third trimester, and diagnosis is formulated more than 24 h after clinical presentation in 50% of cases; second-level imaging is always necessary to reach a definitive diagnosis and start appropriate treatment. A high degree of clinical suspicion is needed to promptly recognize NHAI in pregnancy, thus allowing appropriate multidisciplinary management and timely treatment initiation. Promotion of knowledge and awareness of NHAI as a potential cause of acute abdomen in pregnancy is mandatory to improve clinical practice and, ultimately, perinatal outcomes.
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Affiliation(s)
- Sara Ornaghi
- Department of Obstetrics, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
| | - Federica Fernicola
- Department of Obstetrics, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
| | - Elisabetta Marelli
- Department of Clinical and Biological Sciences, University of Milan, Milan, Italy
- Department of Woman, Mother, and Neonate, Buzzi Children's Hospital-ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Mario Perotti
- Department of Internal Medicine, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | | | - Irene Cameroni
- Department of Obstetrics, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Eloisa M Mariani
- Department of Obstetrics, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Angela I Pincelli
- Department of Internal Medicine, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | | | - Irene Cetin
- Department of Clinical and Biological Sciences, University of Milan, Milan, Italy
- Department of Woman, Mother, and Neonate, Buzzi Children's Hospital-ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Patrizia Vergani
- Department of Obstetrics, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
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2
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Menon L, Edem D, Maradana J, Sharma P, Tamhane S. New-onset primary adrenal insufficiency in pregnancy associated with a unilateral adrenal infarction: a case report. Endocrinol Diabetes Metab Case Rep 2023; 2023:23-0093. [PMID: 37982683 PMCID: PMC10692674 DOI: 10.1530/edm-23-0093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 11/01/2023] [Indexed: 11/21/2023] Open
Abstract
Summary New-onset primary adrenal insufficiency is rare in pregnancy. The symptoms of adrenal insufficiency such as nausea, vomiting and dizziness may be attributed to the pregnancy itself, which can lead to a delay in the diagnosis. The presence of hypotension, hypoglycemia or hyperkalemia should raise the suspicion for adrenal insufficiency. We report the case of a 25-year-old woman who presented with tachycardia, left flank pain and vomiting at 36 weeks' gestation. She was found to have primary adrenal insufficiency and started on hydrocortisone and fludrocortisone with resolution of the vomiting and tachycardia. MRI of the abdomen revealed an acute nonhemorrhagic infarct of the left adrenal gland. The contralateral adrenal gland was normal. Autoimmune and infectious etiologies of primary adrenal insufficiency were ruled out and the adrenal insufficiency was attributed to the unilateral adrenal infarction. Adrenal insufficiency persisted after delivery and then resolved at approximately 16 months post partum. This case highlights the need to test women with unilateral adrenal infarction in pregnancy for the presence of primary adrenal insufficiency. Learning points Adrenal insufficiency should be considered when a pregnant woman develops nausea, vomiting and dizziness in association with hypotension or hypoglycemia. Hypovolemic hyponatremia related to vomiting can occur in pregnancy, but the failure to correct hyponatremia despite adequate IV hydration should raise the suspicion for adrenal insufficiency. Adrenal infarction should be in the differential diagnosis for unilateral flank pain in pregnancy. Other common etiologies for flank pain in pregnancy include nephrolithiasis, pyelonephritis and acute cholecystitis. Unilateral adrenal infarction in pregnancy can lead to the development of primary adrenal insufficiency. Following delivery, these patients need to be monitored for the resolution of the adrenal insufficiency.
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Affiliation(s)
- Lakshmi Menon
- Division of Endocrinology and Metabolism, Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Dinesh Edem
- Division of Endocrinology and Metabolism, Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Jhansi Maradana
- Division of Endocrinology, Mass General Brigham Wentworth Douglass Hospital, Dover, New Hampshire, USA
| | - Pranjali Sharma
- Department of Endocrinology, Diabetes and Metabolism, Parkview Health System, Pueblo, Colorado, USA
| | - Shrikant Tamhane
- Division of Endocrinology and Metabolism, Baptist Health, North Little Rock, Arkansas, USA
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3
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Guyon M, Degez M, Artifoni M, Goronflot T, Misbert E, Dochez V, Winer N. Adrenal Gland Necrosis in Pregnancy: How to Manage? Case Series at Nantes University Hospital and Literature Review. J Clin Med 2023; 12:6036. [PMID: 37762978 PMCID: PMC10531684 DOI: 10.3390/jcm12186036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 09/10/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
Adrenal necrosis is a rare but serious cause of abdominal pain of thrombotic origin during pregnancy. There is often a delay in diagnosis and treatment. The objective was to specify the clinical and paraclinical signs suggestive of adrenal necrosis, making it possible to improve the delay in diagnostic. The secondary objective was to establish a multidisciplinary protocol regarding management. This is a case report of pregnant women with a radiological diagnosis of adrenal gland necrosis. In parallel, we carried out a systematic review in the same period. We studied these patients' clinical, biological and radiological data. We included eight patients with a computed tomography scan diagnosis of adrenal necrosis and fifteen articles in the literature describing twenty-four cases. All the patients presented with the same symptoms. The treatment was based on curative anticoagulation. The diagnosis of adrenal gland necrosis is worth suggesting in view of the array of sudden morphine-resistant abdominal pain associated with a biological inflammatory syndrome. The diagnosis is based on the computed tomography scan. Three to six months of curative anticoagulation is recommended as well as a thrombophilia and endocrinological assessment to rule out adrenal insufficiency.
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Affiliation(s)
- Mathilde Guyon
- Department of Gynecology-Obstetrics, Nantes University Hospital, 44000 Nantes, France (V.D.); (N.W.)
| | - Manon Degez
- Department of Gynecology-Obstetrics, Nantes University Hospital, 44000 Nantes, France (V.D.); (N.W.)
| | - Mathieu Artifoni
- Department of Internal Medicine, Nantes University Hospital, 44000 Nantes, France;
| | - Thomas Goronflot
- Data Clinic, National Institute for Health and Medical Research, Nantes University Hospital, 44000 Nantes, France;
| | - Emilie Misbert
- Department of Gynecology-Obstetrics, Nantes University Hospital, 44000 Nantes, France (V.D.); (N.W.)
| | - Vincent Dochez
- Department of Gynecology-Obstetrics, Nantes University Hospital, 44000 Nantes, France (V.D.); (N.W.)
| | - Norbert Winer
- Department of Gynecology-Obstetrics, Nantes University Hospital, 44000 Nantes, France (V.D.); (N.W.)
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4
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Tschuertz N, Kupczyk P, Poetzsch B, Gembruch U, Merz WM. Unilateral Non-Hemorrhagic Adrenal Infarction in Pregnancy: Case Series and Literature Review. J Clin Med 2023; 12:4855. [PMID: 37510974 PMCID: PMC10381111 DOI: 10.3390/jcm12144855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 07/14/2023] [Accepted: 07/19/2023] [Indexed: 07/30/2023] Open
Abstract
To summarize the evidence on non-hemorrhagic adrenal infarction (NHAI) and identify questions arising in diagnosis and management, cases in the PubMed database were merged with our case series. A total of 92 publications were retrieved, 15 of which reported on NHAI during pregnancy. Including the four in our case series, 24 cases have been described so far. Severe, unremitting pain requiring opioid analgesia was the leading symptom, often combined with nausea and vomiting. Laboratory results were non-contributory in most cases. Diagnosis was established via MRI in nine cases (37.5%) and via CT in six (25%); nine patients (37.5%) underwent both investigations. Location was predominantly on the right side (n = 16, 66.7%). In addition to analgesia, anticoagulation with heparin was commenced in 18 cases (75%). When thrombophilia screening was performed, major thrombogenic polymorphisms were detected in six cases (33.3%). One woman developed signs of adrenal insufficiency. The reported perinatal outcome was unremarkable. Unilateral NHAI has emerged as a rare but important cause of severe abdominal pain in pregnancy. The threshold to perform an MRI in pregnant women with characteristic clinical findings should be low. To prevent fetal radiation exposure, diagnostic imaging via CT should be avoided. In addition to symptomatic treatment with opioid analgesia, initiation of anticoagulant treatment should be strongly considered.
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Affiliation(s)
- Nikolai Tschuertz
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Patrick Kupczyk
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, 53127 Bonn, Germany
| | - Bernd Poetzsch
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Ulrich Gembruch
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Waltraut M Merz
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, 53127 Bonn, Germany
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5
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Hoshino Y, Manaka K, Sato J, Asatsuma Y, Horikoshi H, Takeuchi M, Ito N, Fujita M, Yasunaga M, Matsuda K, Honda A, Maki H, Masamoto Y, Kurokawa M, Nangaku M, Makita N. Recurrent bilateral adrenal infarction with myelodysplastic/myeloproliferative neoplasm-unclassifiable (MDS/MPN-U): a case report. BMC Endocr Disord 2023; 23:128. [PMID: 37277771 DOI: 10.1186/s12902-023-01384-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 05/30/2023] [Indexed: 06/07/2023] Open
Abstract
BACKGROUND Bilateral adrenal infarction is rare and only a small number of cases have been reported so far. Adrenal infarction is usually caused by thrombophilia or a hypercoagulable state, such as antiphospholipid antibody syndrome, pregnancy, and coronavirus disease 2019. However, adrenal infarction with myelodysplastic/myeloproliferative neoplasm (MDS/MPN) has not been reported. CASE PRESENTATION An 81-year-old man with a sudden severe bilateral backache presented to our hospital. Contrast-enhanced computed tomography (CT) led to the diagnosis of bilateral adrenal infarction. Previously reported causes of adrenal infarction were all excluded and a diagnosis of MDS/MPN-unclassifiable (MDS/MPN-U) was reached, which was considered to be attributed to adrenal infarction. He developed a relapse of bilateral adrenal infarction, and aspirin administration was initiated. Partial primary adrenal insufficiency was suspected as the serum adrenocorticotropic hormone level was persistently high after the second bilateral adrenal infarction. CONCLUSION This is the first case of bilateral adrenal infarction with MDS/MPN-U encountered. MDS/MPN has the clinical characteristics of MPN. It is reasonable to assume that MDS/MPN-U may have influenced bilateral adrenal infarction development, considering the absence of thrombosis history and a current comorbid hypercoagulable disease. This is also the first case of recurrent bilateral adrenal infarction. It is important to carefully investigate the underlying cause of adrenal infarction once adrenal infarction is diagnosed, as well as to assess adrenocortical function.
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Affiliation(s)
- Yoshitomo Hoshino
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Katsunori Manaka
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Junichiro Sato
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Yui Asatsuma
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Hirofumi Horikoshi
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Maki Takeuchi
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Nobuaki Ito
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Megumi Fujita
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Megumi Yasunaga
- Department of Hematology and Oncology, The University of Tokyo Hospital, Tokyo, Japan
| | - Kensuke Matsuda
- Department of Hematology and Oncology, The University of Tokyo Hospital, Tokyo, Japan
| | - Akira Honda
- Department of Hematology and Oncology, The University of Tokyo Hospital, Tokyo, Japan
| | - Hiroaki Maki
- Department of Hematology and Oncology, The University of Tokyo Hospital, Tokyo, Japan
| | - Yosuke Masamoto
- Department of Hematology and Oncology, The University of Tokyo Hospital, Tokyo, Japan
| | - Mineo Kurokawa
- Department of Hematology and Oncology, The University of Tokyo Hospital, Tokyo, Japan
- Department of Cell Therapy and Transplantation Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Noriko Makita
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan.
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6
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Paloka R, Gopireddy DR, Virarkar M, Galgano SJ, Morani A, Adimula P, Singareddy A, Montanarella M. Multimodality imaging of adrenal gland pathologies: A comprehensive pictorial review. J Clin Imaging Sci 2022; 12:62. [PMID: 36601600 PMCID: PMC9805616 DOI: 10.25259/jcis_92_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 11/16/2022] [Indexed: 12/03/2022] Open
Abstract
The assessment of acute abdominal and pelvic emergencies typically involves a multimodal approach consisting of plain radiographs, ultrasound, computed tomography (CT), and rarely magnetic resonance imaging (MRI). Although MRI is not traditionally employed in acute care settings, there are several instances in which MRI provides superior functional and prognostic information. In this manuscript, we highlight multimodal findings of adrenal gland emergencies: Hemorrhage, infarction, and infection. The purpose of our study is to highlight significant findings in various modalities, including CT, MRI, ultrasound, and PET/CT. Due to the scarcity of published data and limited clinical use, primary ultrasound findings are limited in our multimodal review. In conclusion, we find that synergistic use of CT, MRI, and functional imaging provides an effective tool for evaluation and management of adrenal pathology.
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Affiliation(s)
- Rinald Paloka
- Department of Radiology, University of Florida Jacksonville, Jacksonville, Florida, United States,Corresponding author: Rinald Paloka, Department of Radiology, University of Florida Jacksonville, Jacksonville, Florida, United States.
| | - Dheeraj Reddy Gopireddy
- Department of Radiology, University of Florida Jacksonville, Jacksonville, Florida, United States
| | - Mayur Virarkar
- Department of Radiology, University of Florida Jacksonville, Jacksonville, Florida, United States
| | - Samuel Joseph Galgano
- Department of Radiology, University of Alabama at Birmingham, Birmingham, United States
| | - Ajaykumar Morani
- Department of Radiology, University of Texas MD Anderson, Houston, Texas, United States
| | - Padma Adimula
- Department of Radiology, University of Florida Jacksonville, Jacksonville, Florida, United States
| | - Anastasia Singareddy
- Department of Radiology, University of Florida Jacksonville, Jacksonville, Florida, United States
| | - Matthew Montanarella
- Department of Radiology, University of Florida Jacksonville, Jacksonville, Florida, United States
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7
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Sapkota S, David S, Sharma S, Shrestha S, Kalla A. Adrenal infarction secondary to methamphetamine use: a case report and review of the literature. J Med Case Rep 2022; 16:379. [PMID: 36258260 PMCID: PMC9578202 DOI: 10.1186/s13256-022-03573-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 08/18/2022] [Indexed: 11/23/2022] Open
Abstract
Background An acute abdomen can have a variety of causes. A commonly missed cause of abdominal pain is direct substance abuse and its sequelae. The use of methamphetamine is rising in the United States resulting in significant morbidity and mortality. There has been no reported case of methamphetamine-induced adrenal infarction based on an extensive review of available literature. Case presentation We present a case of a 34-year-old Hispanic man who presented with acute abdominal pain secondary to adrenal infarction in the setting of methamphetamine use. Left paraumbilical tenderness was present on abdominal examination. Contrast-enhanced CT of the abdomen and pelvis revealed internal hypoenhancement of the left adrenal gland, consistent with acute left adrenal infarction. The patient was managed with enoxaparin and apixaban. Conclusion Substance abuse, especially among young patients, can at times present with acute abdomen. This mandates physicians to be vigilant and take into consideration the history of substance abuse and relevant investigations. Timely diagnosis and management can prevent life-threatening complications.
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Affiliation(s)
- Surendra Sapkota
- Department of Internal Medicine, Ascension Saint Agnes Hospital, 900 S Caton Ave, Baltimore, MD, 21229, USA.
| | - Sarah David
- Ross University School of Medicine, Bridgetown, Barbados
| | | | - Suraj Shrestha
- Maharajgunj Medical Campus, Institute of Medicine, Kathmandu, Nepal
| | - Abhishek Kalla
- Ascension Saint Agnes Hospital, Cancer Institute, Baltimore, MD, USA
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8
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Shah N, Deshmukh H, Akbar MJ, Saeed Y, Akbar S, Malik S, Allan B. Unilateral adrenal infarction in pregnancy with associated acute hypoadrenalism and subsequent spontaneous biochemical and radiological resolution. Clin Case Rep 2022; 10:e05442. [PMID: 35169476 PMCID: PMC8831941 DOI: 10.1002/ccr3.5442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 01/19/2022] [Accepted: 01/31/2022] [Indexed: 11/21/2022] Open
Abstract
Adrenal infarction is a rare cause of abdominal pain during pregnancy, and if missed, it can result in devastating clinical consequences for the mother and the child. The authors report a case of a young female who presented with severe abdominal pain and nausea. The biochemistry showed raised inflammatory markers and significant lactic acidosis. As the cause of the symptoms was not clear and the patient continued to deteriorate, a contrast‐enhanced CT abdomen and pelvis was done which was suggestive of an acute left adrenal infarction. Subsequently, the patient was confirmed to have biochemical hypoadrenalism and required replacement doses of hydrocortisone until recovery of the adrenal glucocorticoid reserve and anticoagulation for the duration of pregnancy. We discuss the workup including diagnostic imaging, follow‐up, and considerations for future pregnancies in this case.
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Affiliation(s)
- Najeeb Shah
- Hull University Teaching Hospitals NHS TrustHull Royal Infirmary Hull UK
- University of Hull Hull UK
| | - Harshal Deshmukh
- Hull University Teaching Hospitals NHS TrustHull Royal Infirmary Hull UK
- University of Hull Hull UK
| | | | - Yamna Saeed
- Hull University Teaching Hospitals NHS TrustHull Royal Infirmary Hull UK
| | - Shahzad Akbar
- York and Scarborough Teaching Hospitals NHS Foundation Trust York UK
| | - Shah Malik
- Hull University Teaching Hospitals NHS TrustHull Royal Infirmary Hull UK
| | - Belinda Allan
- Hull University Teaching Hospitals NHS TrustHull Royal Infirmary Hull UK
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9
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Jerbaka M, Slaiby T, Farhat Z, Diab Y, Toufayli N, Rida K, Diab T. Left flank pain during pregnancy with an unpredictable etiology: think of nonhemorrhagic adrenal infarction. Future Sci OA 2021; 7:FSO718. [PMID: 34295536 PMCID: PMC8288222 DOI: 10.2144/fsoa-2021-0022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 05/06/2021] [Indexed: 12/02/2022] Open
Abstract
Abdominal pain is the most presenting complaint during pregnancy with multiple etiologies. The diagnosis could be unpredictable. We present a case of 36-year-old pregnant woman gravida 10 para 7 abortus 2 at 36 + 5 weeks of gestation presenting twice for an increasing left abdominal pain, not relieved despite analgesics. She was delivered for severe oligohydramnios. After delivery, she was found to have a left adrenal infarction on computed tomography scan. She was found to have two mutations of the gene MTHFR 677CC. Our presented case should remind physicians to consider the presence of thromboembolic state during pregnancy. The diagnosis of adrenal infarction should be among the differentials of an ambiguous flank pain that is resilient to medical therapy. Diagnosis in a pregnant patient can be easily confirmed with MRI, after which anticoagulation should be started and the workup for hypercoagulable state investigated.
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Affiliation(s)
- Myriam Jerbaka
- Department of Gynecology & Obstetrics, Saint Joseph University, Lebanese University, Bahman University Hospital, Beirut, Lebanon
| | - Tracy Slaiby
- Department of Gynecology & Obstetrics, Saint Joseph University, Lebanese University, Bahman University Hospital, Beirut, Lebanon
| | - Zahraa Farhat
- Department of Gynecology & Obstetrics, Saint Joseph University, Lebanese University, Bahman University Hospital, Beirut, Lebanon
| | - Yara Diab
- Department of Gynecology & Obstetrics, Lebanese American University, Rizk University, Beirut, Lebanon
| | - Nawal Toufayli
- Department of Gynecology & Obstetrics, Bahman university hospital, Beirut Lebanon
| | - Khaled Rida
- Department of General Surgery, Bahman University Hospital, Beirut, Lebanon
| | - Taghreed Diab
- Department of Gynecology & Obstetrics, Bahman university hospital, Beirut Lebanon
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10
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Padilla RM, Way AR, Soule E, Gopireddy D, Lall C. Diffusion Weighted Imaging in Unilateral Adrenal Infarction: A Case of Colicky Right Upper Quadrant Pain in a Pregnant Female. Cureus 2021; 13:e13289. [PMID: 33728222 PMCID: PMC7949625 DOI: 10.7759/cureus.13289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2021] [Indexed: 11/08/2022] Open
Abstract
Diffusion weighted imaging (DWI) is a magnetic resonance imaging (MRI) non-contrast sequence that can indicate tissue ischemia or infarction. Adrenal infarct may present similarly to biliary or gallbladder pathologies, and the differential diagnosis during emergency work-up can be narrowed utilizing DWI sequences. In this paper, we describe the usefulness of DWI for urgent diagnosis in a case of non-hemorrhagic adrenal infarct of a pregnant female presenting with right upper quadrant pain. Although uncommon, adrenal infarct may occur in patients with hypercoagulability and localizing pain that is unexplained by other imaging modalities. We outline the imaging features of DWI in evaluating adrenal infarct as a safe and time effective application for patients with contraindications to imaging with ionizing radiation.
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Affiliation(s)
- Rebekah M Padilla
- Diagnostic Radiology, University of Florida College of Medicine, Jacksonville, USA
| | - Ashley R Way
- Radiology, University of Florida College of Medicine, Jacksonville, USA
| | - Erik Soule
- Interventional Radiology, University of Florida College of Medicine, Jacksonville, USA
| | - Dheeraj Gopireddy
- Radiology, University of Florida College of Medicine, Jacksonville, USA
| | - Chandana Lall
- Abdominal Imaging, University of Florida College of Medicine, Jacksonville, USA
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11
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Abstract
The adrenal glands may be overlooked when evaluating acutely ill patients. Acute adrenal disorders may result from complications of an underlying systemic disease, which may be unsuspected clinically. Various acute adrenal emergencies including trauma, spontaneous hemorrhage, infarction and infection can be diagnosed using CT and MRI; however, in uncertain cases follow-up to resolution of imaging findings or histological sampling may be required for diagnosis.
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Affiliation(s)
- Amar Udare
- Department of Medical Imaging, The Ottawa Hospital, The University of Ottawa, 1053 Carling Avenue, Ottawa, ONK1Y 4E9, Canada
| | - Minu Agarwal
- Department of Diagnostic Imaging, Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, McMaster University, Hamilton, ONL8V 1C3, Canada
| | - Evan Siegelman
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, MRI - 1 Founders, Philadelphia, PA, 19104-4283, USA
| | - Nicola Schieda
- The Ottawa Hospital, the University of Ottawa, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada.
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12
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Sidibe S, Perazzini C, Cassagnes L, Boyer L, Magnin B. The role of computed tomography in adrenal gland infarction diagnosis during pregnancy: Two case reports. JOURNAL DE MÉDECINE VASCULAIRE 2020; 46:28-31. [PMID: 33546818 DOI: 10.1016/j.jdmv.2020.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 11/21/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Seydou Sidibe
- Radiology Department, University Hospital Gabriel Montpied, 58, rue Montalembert, 63000 Clermont-Ferrand, France
| | - Chiara Perazzini
- Radiology Department, University Hospital Gabriel Montpied, 58, rue Montalembert, 63000 Clermont-Ferrand, France.
| | - Lucie Cassagnes
- Radiology Department, University Hospital Gabriel Montpied, 58, rue Montalembert, 63000 Clermont-Ferrand, France
| | - Louis Boyer
- Radiology Department, University Hospital Gabriel Montpied, 58, rue Montalembert, 63000 Clermont-Ferrand, France
| | - Benoit Magnin
- Radiology Department, University Hospital Estaing, Clermont-Ferrand, France
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13
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Chasseloup F, Bourcigaux N, Christin-Maitre S. Unilateral nonhaemorrhagic adrenal infarction as a cause of abdominal pain during pregnancy. Gynecol Endocrinol 2019; 35:941-944. [PMID: 31155980 DOI: 10.1080/09513590.2019.1622088] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Adrenal infarction is usually associated with bilateral adrenal hemorrhage in the setting of antiphospholipid syndrome or hemodynamic variation. Few cases of unilateral nonhemorrhagic adrenal infarction (NHAI) have been described in the literature. Here, we report a case occurring during pregnancy. A 30-year-old woman presented at 32 weeks of gestation with sudden-onset right abdominal pain and contractions. Unilateral adrenal infarction was diagnosed following computed tomography (CT). It showed an enlarged right adrenal, without hyperenhancement. Because of persisting contractions, despite medical care, she delivered a healthy, albeit premature, girl. Abdominal pain decreased right after delivery. Three month later, CT imaging showed atrophy of the right adrenal and a normal left adrenal. The patient's adrenal hormonal function was normal. Accurate diagnosis of NHAI remains difficult as its clinical presentation is not specific. It can only be performed with adrenal imaging. Magnetic resonance imaging shows diffuse enlargement of one or both adrenals and an edema on T2-weighted images. Anticoagulation therapy may be discussed. Patients should be evaluated between 3 and 6 months after the event to assess adrenal size and function. In summary, NHAI during pregnancy is probably underdiagnosed and obstetricians should be aware of this or diagnostic difficulty.
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Affiliation(s)
- F Chasseloup
- Department of Endocrinology, University Hospital Saint-Antoine , Paris , France
| | - N Bourcigaux
- Department of Endocrinology, University Hospital Saint-Antoine , Paris , France
| | - S Christin-Maitre
- Department of Endocrinology, University Hospital Saint-Antoine , Paris , France
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Agarwal KA, Soe MH. Cryptogenic adrenal infarction: a rare case of unilateral adrenal infarction in a pregnant woman. BMJ Case Rep 2019; 12:12/3/e228795. [PMID: 30917968 DOI: 10.1136/bcr-2018-228795] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Adrenal infarction is a rare event, especially in pregnancy. The diagnosis is challenging because patients present with acute abdomen and initial workup are usually unrevealing. We present a case of unilateral adrenal infarction in a pregnant young woman without any other causes of thrombophilia, who presented with acute abdominal pain and an unremarkable initial workup. MRI and contrast-enhanced CT scan revealed a non-haemorrhagic infarct of the right adrenal gland. Our case highlights the importance of considering this rare diagnosis in the differential for a pregnant woman with acute abdomen without any obvious surgical cause.
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Affiliation(s)
- Krishna Adit Agarwal
- Baystate Medical Center, University of Massachusetts, Springfield, Massachusetts, USA
| | - Myat Han Soe
- Baystate Medical Center, University of Massachusetts, Springfield, Massachusetts, USA
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Cunningham TK, Maydanovych S, Draper H, Antoniades G, Allen J. Adrenal infarction in the immediate postnatal period†. J OBSTET GYNAECOL 2018; 39:410-411. [PMID: 30286671 DOI: 10.1080/01443615.2018.1472557] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
| | - Slavyana Maydanovych
- a The Women and Children's Hospital, Hull Royal Infirmary , Hull , United Kingdom
| | - Hannah Draper
- a The Women and Children's Hospital, Hull Royal Infirmary , Hull , United Kingdom
| | | | - Jane Allen
- a The Women and Children's Hospital, Hull Royal Infirmary , Hull , United Kingdom
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Acute Nonhemorrhagic Adrenal Infarction in Pregnancy: 10-Year MRI Incidence and Patient Outcomes at a Single Institution. AJR Am J Roentgenol 2018; 210:785-791. [PMID: 29446684 DOI: 10.2214/ajr.17.18739] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study was to retrospectively investigate the MRI incidence of nonhemorrhagic adrenal infarction in pregnant women undergoing MRI evaluation of acute abdominal or flank pain, assess the MRI features quantitatively, and report patient outcomes. MATERIALS AND METHODS All abdominal MRI examinations of pregnant women with acute pain at one institution from May 2005 to April 2015 were reviewed. The adrenals were evaluated for abnormal morphologic and signal intensity characteristics described in the literature characterizing nonhemorrhagic adrenal infarction and were compared with the contralateral adrenal by paired t tests. The findings were correlated with clinical presentation. Patient demographics and outcomes were gathered from the medical record. RESULTS Findings of nonhemorrhagic adrenal infarction were present in 5 of 379 (1.3%) examinations of four pregnant patients (mean age, 28 years; range, 20.8-33.9 years; mean gestational age, 26 weeks; range, 16-35 weeks). MRI features included lengthening (mean, 39.8 versus 21.2 mm) (p = 0.005) and increased T2 signal intensity (p = 0.001) of the infarcted adrenal with surrounding edema and without T1 signal intensity suggesting hemorrhage. No alternative diagnosis was identified. All patients presented with severe acute abdominal or flank pain on the same side as the MRI findings, tenderness to palpation, and mild leukocytosis. All women delivered healthy infants. CONCLUSION Unilateral nonhemorrhagic adrenal infarction was identified in 1.3% of abdominal MRI examinations performed for pregnant women with acute abdominal or flank pain. Knowledge of the MRI characteristics of this entity is important for recognizing it and may prevent further potentially invasive tests, procedures, or missed diagnoses.
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Langlois F, Lim DST, Fleseriu M. Update on adrenal insufficiency: diagnosis and management in pregnancy. Curr Opin Endocrinol Diabetes Obes 2017; 24:184-192. [PMID: 28288009 DOI: 10.1097/med.0000000000000331] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Adrenal insufficiency in pregnancy, although relatively rare, has significant clinical implications on both maternal and fetal outcomes. Hypothalamo-pituitary-adrenal axis dynamics and physiological changes are complex, thus diagnosis and management of adrenal insufficiency in pregnancy remain challenging. RECENT FINDINGS Studies consistently demonstrate a rise in total serum cortisol with pregnancy, but less data are available on free cortisol levels. Salivary cortisol values have been measured in normal pregnancy and in a few studies using healthy nonpregnant women controls. Although this adds to our current knowledge of hypothalamo-pituitary-adrenal axis changes in pregnancy, clear-cut cortisol reference ranges are yet to be established. Serum cortisol and the cosyntropin stimulation test (albeit with higher peak cortisol thresholds) are currently the diagnostic tests of choice. Hydrocortisone is the preferred glucocorticoid replacement in pregnancy as it is inactivated by placental 11-β-hydroxysteroid dehydrogenase 2; dose titration may be required, but should be individualized depending on clinical course and mode of delivery. SUMMARY Further studies on the long-term effects of maternal glucocorticoid regimens on the fetus and potential modulators of fetal glucocorticoid sensitivity and placental 11-β-hydroxysteroid dehydrogenase 2 are needed and will be useful in guiding clinical management strategies in pregnant women with adrenal insufficiency.
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Affiliation(s)
- Fabienne Langlois
- aDivision of Endocrinology, Diabetes and Metabolism, Department of Medicine bDepartment of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA
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