ESA-SRB-AOTA 2019

Primary adrenal insufficiency due to heparin-induced thrombotic thrombocytopaenia syndrome (HITTS): a case report (#634)

Matthew Sawyer 1 2 , Andy Lim 1 3 , Aditya Tedjaseputra 4
  1. General Medicine, Monash Health, Melbourne, VIC, Australia
  2. Endocrinology, Eastern Health, Melbourne, VIC, Australia
  3. Department of Medicine, Monash University, Melbourne, VIC, Australia
  4. Haematology, Monash Health, Melbourne, VIC, Australia

An 83-year-old woman underwent an elective total hip joint replacement. Warfarin for atrial fibrillation was withheld perioperatively and her admission was complicated by pulmonary embolism (PE) diagnosed on CTPA on day two post-operatively. She was recommenced on warfarin and discharged with bridging therapeutic enoxaparin. She presented to a different hospital the following day with pleuritic chest pain and became hypoxic. Repeat CTPA did not demonstrate PE, however left lower lobe consolidation was evident.

Her haemoglobin was noted to acutely decline from 122 to 84g/L (110-160) in a period of six hours without an overt source of bleeding, however remained stable thereafter. CT A/P identified ill-defined hypodensities in the expected region of the adrenal glands, suspicious for haemorrhage.

On review, the patient reported generalised abdominal pain and was drowsy. Morning cortisol was 47 nmol/L (185-625) and ACTH was 162 pmol/L (<10). She became progressively hyponatraemic from 133 to 126 mmol/L, but not hyperkalaemic. Her systolic blood pressure trended down from 150-160mmHg but was maintained at above 120mmHg. MRI of the adrenals supported the diagnosis of bilateral adrenal haemorrhage. Repeat cortisol the following day was undetectable (<11) and IV hydrocortisone was commenced.

Her platelet count was concurrently noted to have declined to 44x10^9/L (150-450) from 135 three days earlier. A high pre-test probability for heparin induced thrombotic thrombocytopaenia syndrome (HITTS) was reflected in a positive ELISA, confirmed on serotonin release assay, and she was commenced on fondaparinux. Following the resolution of thrombocytopaenia without further thrombotic sequelae she was discharged on hydrocortisone, fludrocortisone and warfarin.

This case highlights an atypical presentation and evolution of primary adrenal insufficiency due to adrenal haemorrhage in the context of HITTS. Notably this occurred in the absence of shock, which is near universal, but with a relative hypotension, and thus may be difficult to recognise clinically.5ced1383c17be-Timeline.jpg

  1. Rosenberger LH, Smith PW, Sawyer RG, Hanks JB, Adams RB, Hedrick TL. Bilateral adrenal hemorrhage: the unrecognized cause of hemodynamic collapse associated with heparin-induced thrombocytopenia. Crit Care Med. 2011;39(4):833.
  2. Kurtz LE, Yang S. Bilateral adrenal hemorrhage associated with heparin induced thrombocytopenia. Am J Hematol. 2007;82(6):493-4.
  3. Rao RH, Vagnucci AH, Amico JA. Bilateral massive adrenal hemorrhage: early recognition and treatment. Ann Intern Med. 1989;110(3):227.