Interactive Quiz: Bilateral Flank Pain
Welcome to Rheumatology Consultant's latest interactive diagnostic quiz. Over the next few pages, we'll present a case and ask you to make the diagnosis and treat the patient. Along the way, we'll provide details about the case, and at the end, we'll share the patient's outcome.
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First, let’s meet the patient…
A 33-year-old man presented with bilateral flank pain associated with nausea and vomiting 10 days after having undergone an uncomplicated laparoscopic cholecystectomy. He denied having had fever, chills, hematuria, or dysuria.
In the last 2 years, he had had multiple emergency department visits for episodic abdominal pain. He had developed left iliac vein thrombosis resulting in stent placement 5 years prior at another facility and had received a diagnosis of antiphospholipid syndrome (APLS). He had been lost to follow-up and had prematurely discontinued anticoagulation.
His abdomen was soft, with mild diffuse tenderness. No physical examination findings were suggestive of appendicitis or pyelonephritis.
Are you correct? >>
Answer: Rheumatoid factor test
Laboratory test results showed a white blood cell count of 6050/µL (reference range, 4500-11,000/µL), a hemoglobin level of 13.9 g/dL (reference range, 14.0-17.5 g/dL), a hematocrit level of 40.6% (reference range, 41%-50%), and a platelet count of 87.6 × 103/µL (reference range, 150-350 × 103/µL). Results of a comprehensive metabolic panel showed a sodium concentration of 122 mEq/L (reference range, 136-142 mEq/L), a potassium concentration of 2.9 mEq/L (reference range, 3.5-5.0 mEq/L), a chloride concentration of 83 mEq/L (reference range, 96-106 mEq/L), and a creatinine level of 1.0 mg/dL (reference range, 0.6-1.2 mg/dL). Results of liver function tests were normal.
Furthermore, the prothrombin time was 13.8 s (reference range, 9-12 s), the activated partial thromboplastin time was 61.2 s (reference range, 24-35 s), and the thrombin time was 16.1 s (reference value, <20 s). Results of urinalysis with microscopic examination and urine toxicology testing did not show any abnormalities.
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Answer: Computed tomography scan
Computed tomography (CT) scans of the abdomen (Figures 1 and 2) showed acute bilateral adrenal gland enlargement. Compared with abdominal CT scans done 10 days prior for acute cholecystitis, these findings were new.
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Answer: Acute bilateral adrenal hemorrhage
The findings from the new CT scans were highly suggestive of acute bilateral adrenal hemorrhage. The patient’s serum cortisol level was found to be <0.16 µg/dL (reference range, 5-25 µg/dL). He remained hemodynamically stable. Results of repeated laboratory tests for APLS, including anticardiolipin antibody and lupus anticoagulant testing, were positive for APLS.
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Answer: Both warfarin and corticosteroid replacement therapy
Acute bilateral adrenal hemorrhage requires prompt diagnosis and empirical treatment with corticosteroids to avoid the development of hemodynamic instability and shock. The patient was started on a regimen of warfarin, with a target international normalized ratio of 3.0 to 3.5, and corticosteroid replacement therapy with hydrocortisone and fludrocortisone.
Usual daily doses range between 150 and 200 mg of hydrocortisone. These dosages are tapered down over a few days to replacement regimens of 15 to 30 mg hydrocortisone or equivalent in divided doses, along with mineralocorticoids.
At 8 weeks of follow-up, the patient remained hemodynamically stable, and his abdominal pain had resolved. He continues to be on anticoagulation and corticosteroid replacement regimens.
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Answer: Yes
The degree of involvement of the adrenal glands at initial presentation determines the need for lifelong corticosteroid replacement. Given the extensive involvement of the adrenal glands in this case, the providers anticipate that the patient will benefit from lifelong corticosteroid replacement therapy.
Authors:
Osama Mukarram, MD; Adnan Haider, MD; Ahmed Khan, MD; and Mary Mok, MD
Texas Tech University Health Sciences Center at the Permian Basin, Odessa, Texas
To read the full case report, see:
Mukarram O, Haider A, Khan A, Mok M. Bilateral adrenal hemorrhage in a patient with antiphospholipid syndrome. Consultant. 2017;57(2):128-129. https://www.consultant360.com/articles/bilateral-adrenal-hemorrhage-patient-antiphospholipid-syndrome.