Page 24 - Delaware Medical Journal - February 2018
P. 24
Acute Bilateral Adrenal Hemorrhage on Apixaban
Stephen Lazar, DO; Shailja Roy, MD; Kush Sachdeva, MD; Lin Zheng, MD
BACKGROUND
The development of novel oral anticoagulants (NOACs) that bypass depletion of the Vitamin K-dependent clotting factors, in need of long-term anticoagulation. However, the potential for bleeding can still manifest both in individuals with and without recent history of trauma. Although sometimes clinically obvious, hemorrhage on autopsy is 1.1 percent, taking into account that the 1
The purpose of this case report is to illustrate the risk factors and management of a rare and potentially life-threatening condition
in a patient taking long-term anticoagulation that manifested
days after hospital discharge when his therapy was switched to apixaban after having been diagnosed with recurrent deep venous thrombosis while taking warfarin. Furthermore, the report also serves to highlight the unusual location of bleeding in a patient taking this medication, which has not yet been described in detail in existing literature. Finally, this report further serves to illustrate the management of concurrent bleed and thrombosis.
CASE PRESENTATION
The case involves a 49-year-old male with a history of non-insulin dependent diabetes mellitus, morbid obesity, multiple recurrent bilateral deep venous thromboses, venous stasis with chronic
leg wounds, and hypertension who was discharged from the inpatient setting after a 12-day stay. He was treated for erysipelas and tinea pedis of the left lower extremity with intravenous antibiotics and a one-time dose of an oral antifungal. During
his hospital course, an ultrasound of the left lower extremity
was performed, revealing an acute recurrent non-occlusive
deep venous thrombosis while taking warfarin, despite a therapeutic international normalized ratio (INR) of 2.2, as well as prothrombin time (PT) of 26 seconds and a partial thromboplastin time (PTT) of 108.3 seconds at the time of admission. Because
of a new event, a warfarin failure was entertained, and he was switched to apixaban. He had previously been taking warfarin for anticoagulation for over 10 years, but it should be noted that he was temporarily trialed on rivaroxaban for eight months, and
then switched back to warfarin nine months prior to this past admission when his thrombosis progressed on rivaroxaban. He has no family history of thrombosis.
He had visited the emergency room twice since his most recent hospital discharge. His workup included a computed tomography scan of the abdomen and pelvis without intravenous contrast performed six days after discharge. The radiology interpretation adrenal gland.
Five days after his imaging, he was re-admitted after presenting a third time with over one week of abdominal pain. It was initially described as sharp, but later dull, and localized diffusely to the epigastric area. The pain was exacerbated by inspiration and position, and was unaffected by intake of food. The pain did not radiate to the back. The patient had diarrhea when the pain started six days prior to admission, but hadn’t moved his bowels in the vomiting, fevers, chills, chest pain, dyspnea, and dysuria. His medications at the time of admission included apixaban 5 mg twice daily, glimepiride, lisinopril, metformin, and acetaminophen as admission. His most recent dose of apixaban was on the day of presentation to the emergency room.
Aside from a pulse of 115 beats per minute, his vital signs were unremarkable. He was in no acute distress. His abdomen was soft and obese with mild to moderate tenderness in all four quadrants. His legs showed 2+ pitting edema bilaterally, dorsalis pedis, and posterior tibia pulses were palpable bilaterally. Venous stasis changes with hyperpigmentation were noted bilaterally, and he had a right lateral leg ulceration with a granular wound base with mild serous drainage.
Initial laboratory values were notable for serum sodium of 132 mmol/L, serum potassium of 4.1 mmol/L, serum bicarbonate of 28 mmol/L, and hemoglobin was 11.4 g/dl. His initial PT was 32.9 seconds, PTT was 105.4 seconds, and his INR was 2.7.
Another computed tomography scan was obtained on this
adrenal glands, with the right measuring 6.3 by 3.9 centimeters
stranding seen on previous examination was slightly increased
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Del Med J | February 2017 | Vol. 90 | No. 2
