Diagnosis and Treatment > Signs and Symptoms
Search for other papers by Kaja Grønning in
Google Scholar
PubMed
Search for other papers by Archana Sharma in
Google Scholar
PubMed
Search for other papers by Maria Adele Mastroianni in
Google Scholar
PubMed
Search for other papers by Bo Daniel Karlsson in
Google Scholar
PubMed
Department of Medicine, Haukeland University Hospital, Bergen, Norway
Search for other papers by Eystein S Husebye in
Google Scholar
PubMed
Department of Medicine, Haukeland University Hospital, Bergen, Norway
Search for other papers by Kristian Løvås in
Google Scholar
PubMed
Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
Search for other papers by Ingrid Nermoen in
Google Scholar
PubMed
Summary
Primary adrenal lymphoma (PAL) is a rare cause of adrenal insufficiency. More than 90% is of B-cell origin. The condition is bilateral in up to 75% of cases, with adrenal insufficiency in two of three patients. We report two cases of adrenal insufficiency presenting at the age of 70 and 79 years, respectively. Both patients had negative 21-hydroxylase antibodies with bilateral adrenal lesions on CT. Biopsy showed B-cell lymphoma. One of the patients experienced intermittent disease regression on replacement dosage of glucocorticoids.
Learning points:
-
Primary adrenal lymphoma (PAL) is a rare cause of adrenal insufficiency.
-
Bilateral adrenal masses of unknown origin or in individuals with suspected extra-adrenal malignancy should be biopsied quickly when pheochromocytoma is excluded biochemically.
-
Steroid treatment before biopsy may affect diagnosis.
-
Adrenal insufficiency with negative 21-hydroxylase antibodies should be evaluated radiologically.
Search for other papers by Diana Oliveira in
Google Scholar
PubMed
Search for other papers by Mara Ventura in
Google Scholar
PubMed
Search for other papers by Miguel Melo in
Google Scholar
PubMed
Search for other papers by Sandra Paiva in
Google Scholar
PubMed
Search for other papers by Francisco Carrilho in
Google Scholar
PubMed
Summary
Addison’s disease (AD) is the most common endocrine manifestation of antiphospholipid syndrome (APS), but it remains a very rare complication of the syndrome. It is caused by adrenal venous thrombosis and consequent hemorrhagic infarction or by spontaneous (without thrombosis) adrenal hemorrhage, usually occurring after surgery or anticoagulant therapy. We present a clinical case of a 36-year-old female patient with a previous diagnosis of APS. She presented with multiple thrombotic events, including spontaneous abortions. During evaluation by the third episode of abortion, a CT imaging revealed an adrenal hematoma, but the patient was discharged without further investigation. A few weeks later, she presented in the emergency department with manifestations suggestive of adrenal insufficiency. Based on that assumption, she started therapy with glucocorticoids, with significant clinical improvement. After stabilization, additional investigation confirmed AD and excluded other etiologies; she also started mineralocorticoid replacement. This case illustrates a rare complication of APS that, if misdiagnosed, may be life threatening. A high index of suspicion is necessary for its diagnosis, and prompt treatment is crucial to reduce the morbidity and mortality potentially associated.
Learning points:
-
AD is a rare but life-threatening complication of APS.
-
It is important to look for AD in patients with APS and a suggestive clinical scenario.
-
APS must be excluded in patients with primary adrenal insufficiency and adrenal imaging revealing thrombosis/hemorrhage.
-
Glucocorticoid therapy should be promptly initiated when AD is suspected.
-
Mineralocorticoid replacement must be started when there is confirmed aldosterone deficiency.
-
Hypertension is a common feature of APS; in patients with APS and AD, replacement therapy with glucocorticoids and mineralocorticoids may jeopardize hypertension management.
Search for other papers by Benedetta Zampetti in
Google Scholar
PubMed
Search for other papers by Roberto Attanasio in
Google Scholar
PubMed
Search for other papers by Renato Cozzi in
Google Scholar
PubMed
Summary
A 69-year-old male was admitted for severe hyponatremia disclosed after an accidental fall. He was anticoagulated from 2 months after the implantation of a biologic aortic valve prosthesis. The work-up disclosed adrenal failure and MRI showed bilateral adrenal hemorrhage. Clinical picture and lab parameters normalized quickly after the appropriate replacement treatment. Anticoagulation excess should be added to the list of drugs potentially causing hyponatremia.
Learning points:
-
Hyponatremia requires a complete and timely workup in order to start an appropriate treatment for the improvement of clinical conditions.
-
History is crucial: a detailed list of drugs potentially causing hyponatremia should be collected. Anticoagulants should be added to the list, mostly in the event of excessive anticoagulation.
-
Intra-adrenal hemorrhage is a rare cause of hyponatremia and adrenal failure.
-
The ACTH test is still the gold standard for the diagnosis of hypoadrenalism.
