Bilateral adrenal haemorrhage complicated by sepsis, coagulopathy, influenza A and adrenal crisis

2020 ◽  
Vol 13 (12) ◽  
pp. e238628
Author(s):  
Eanna Mulvihill ◽  
Martin Gannon ◽  
Ananthapadmanaban Balasubramaniam ◽  
John Fitzpatrick
Keyword(s):  
Influenza A ◽  
Physiological Stress ◽  
Epigastric Pain ◽  
Tertiary Hospital ◽  
Adrenal Crisis ◽  
Adrenal Haemorrhage ◽  
Unit Management ◽  
Failure Assessment ◽  
Synacthen Test ◽  
Short Synacthen Test

Bilateral adrenal haemorrhage is a rare and often fatal condition that most commonly occurs under conditions of severe physiological stress. We describe a 33-year-old male patient with ulcerative colitis who presented with acute worsening epigastric pain, vomiting and raised inflammatory markers. Initial differentials included gastritis and peptic ulceration. Gastroscopy revealed no abnormalities. By day 3, he had developed sepsis with a sequential organ failure assessment score of 2 as well as coagulopathy. A subsequent CT scan diagnosed bilateral adrenal haemorrhage. A short Synacthen Test confirmed adrenal insufficiency and he was treated with replacement steroids and antibiotics for a possible urinary tract infection or pyelonephritis and he recovered well. Several days later he developed fever, dyspnoea and a productive cough. Subsequently, he became hypotensive (Blood Pressure (BP) 95/65 mm Hg) and unresponsive with a Glasgow Coma Scale of 7 and was hyponatraemic and hyperkalaemic. He was intubated and transferred to a tertiary hospital for intensive care unit management where investigations confirmed the patient to be influenza A positive.

scholarly journals Adrenal haemorrhage as a complication of COVID-19 infection

2020 ◽  
Vol 13 (11) ◽  
pp. e239643
Author(s):  
Noor Sharrack ◽  
Conal Thomas Baxter ◽  
Michael Paddock ◽  
Elizabeth Uchegbu
Keyword(s):  
Unusual Complication ◽  
Adrenal Haemorrhage ◽  
Heparin Infusion ◽  
Pulmonary Angiogram ◽  
Intravenous Heparin ◽  
Ct Pulmonary Angiogram ◽  
Synacthen Test ◽  
The Right ◽  
Short Synacthen Test

We report an unusual complication of COVID-19 infection in a 53-year-old Caucasian man. He presented with shortness of breath, fever and pleuritic chest pain. A CT pulmonary angiogram (CTPA) demonstrated acute bilateral pulmonary embolism and bilateral multifocal parenchymal ground glass change consistent with COVID-19 (SARS-CoV-2) infection. Right adrenal haemorrhage was suspected on the CTPA which was confirmed on triple-phase abdominal CT imaging. A short Synacthen test revealed normal adrenal function. He was treated initially with an intravenous heparin infusion, which was changed to apixaban with a planned outpatient review in 3 months’ time. He made an uncomplicated recovery and was discharged. Follow-up imaging nearly 5 months later showed near complete resolution of the right adrenal haemorrhage with no CT evidence of an underlying adrenal lesion.

scholarly journals What is the value of the 60‐minute cortisol measurement in the short synacthen test (SST)? Evidence for the defence

2021 ◽  
Vol 75 (8) ◽  
Author(s):  
Maria Michaelidou ◽  
Ghasem Yadegarfar ◽  
Lauren Morris ◽  
Samantha Dolan ◽  
Adam Robinson ◽  
...  
Keyword(s):  
Synacthen Test ◽  
Short Synacthen Test

Epidemiological analysis of critically ill adult patients with pandemic influenza A(H1N1) in South Korea

2012 ◽  
Vol 141 (5) ◽  
pp. 1070-1079 ◽  
Author(s):  
S. B. HONG ◽  
E. Y. CHOI ◽  
S. H. KIM ◽  
G. Y. SUH ◽  
M. S. PARK ◽  
...  
Keyword(s):  
South Korea ◽  
Influenza A ◽  
Multivariate Logistic Regression Analysis ◽  
H1n1 Influenza ◽  
Epidemiological Analysis ◽  
Influenza A H1n1 ◽  
Failure Assessment ◽  
2009 H1n1 ◽  
Independent Risk Factors ◽  
Chronic Comorbidities

SUMMARYA total of 245 patients with confirmed 2009 H1N1 influenza were admitted to the intensive-care units of 28 hospitals (South Korea). Their mean age was 55·3 years with 68·6% aged >50 years, and 54·7% male. Nine were obese and three were pregnant. One or more comorbidities were present in 83·7%, and nosocomial acquisition occurred in 14·3%. In total, 107 (43·7%) patients received corticosteroids and 66·1% required mechanical ventilation. Eighty (32·7%) patients died within 30 days after onset of symptoms and 99 (40·4%) within 90 days. Multivariate logistic regression analysis showed that the clinician's decision to prescribe corticosteroids, older age, Sequential Organ Failure Assessment score and nosocomial bacterial pneumonia were independent risk factors for 90-day mortality. In contrast with Western countries, critical illness in Korea in relation to 2009 H1N1 was most common in older patients with chronic comorbidities; nosocomial acquisition occurred occasionally but disease in obese or pregnant patients was uncommon.

Adrenal insufficiency in kidney transplant patients during low-dose prednisolone therapy: a cross-sectional case–control study

2019 ◽  
Vol 35 (12) ◽  
pp. 2191-2197 ◽  
Author(s):  
Amalie Valentin ◽  
Stina Willemoes Borresen ◽  
Marianne Rix ◽  
Thomas Elung-Jensen ◽  
Søren Schwartz Sørensen ◽  
...  
Keyword(s):  
Adrenal Insufficiency ◽  
Low Dose ◽  
Case Control Study ◽  
Case Control ◽  
Adrenal Crisis ◽  
Control Group ◽  
Cross Sectional ◽  
Prednisolone Treatment ◽  
Synacthen Test ◽  
Control Study

Abstract Background Maintenance immunosuppressive regimens after renal transplantation (RTx) most often include prednisolone, which may induce secondary adrenal insufficiency, a potentially life-threatening side effect to glucocorticoid (GC) treatment due to the risk of acute adrenal crisis. We investigated the prevalence of prednisolone-induced adrenal insufficiency in RTx patients receiving long-term low-dose prednisolone treatment. Methods We performed a case–control study of patients on renal replacement therapy differing in terms of GC exposure. The study included 30 RTx patients transplanted >11 months before enrolment in the study and treated with prednisolone (5 or 7.5 mg prednisolone/day for ≥6 months) and 30 dialysis patients not treated with prednisolone. Patients underwent testing for adrenal insufficiency by a 250-µg Synacthen test performed fasting in the morning after a 48-h prednisolone pause. Normal adrenal function was defined as P-cortisol ≥420 nmol/L 30 min after Synacthen injection. This cut-off is used routinely for the new Roche Elecsys Cortisol II assay and is validated locally based on the Synacthen test responses in 100 healthy individuals. Results Thirteen RTx patients {43% [95% confidence interval (CI) 27–61]} had an insufficient response to the Synacthen test compared with one patient in the control group [3% (95% CI 0.6–17)] (P = 0.0004). Insufficient responses were seen in 9/25 and 4/5 RTx patients treated with 5 and 7.5 mg prednisolone/day, respectively. Conclusions We found a high prevalence of adrenal insufficiency among RTx patients receiving low-dose prednisolone treatment. We therefore advocate for increased clinical alertness towards prednisolone-induced adrenal insufficiency in RTx patients and thus their potential need of rescue GC supplementation during stress.

scholarly journals Adrenal suppression from glucocorticoids: preventing an iatrogenic cause of morbidity and mortality in children

2019 ◽  
Vol 3 (1) ◽  
pp. e000569 ◽  
Author(s):  
Alexandra Ahmet ◽  
Arati Mokashi ◽  
Ellen B Goldbloom ◽  
Celine Huot ◽  
Roman Jurencak ◽  
...  
Keyword(s):  
Risk Factors ◽  
Side Effect ◽  
Healthcare Professionals ◽  
Inhaled Corticosteroids ◽  
Physiological Stress ◽  
Current Knowledge ◽  
Adrenal Suppression ◽  
Adrenal Crisis ◽  
Children At Risk ◽  
Specific Symptoms

Adrenal suppression (AS) is an important side effect of glucocorticoids (GCs) including inhaled corticosteroids (ICS). AS can often be asymptomatic or associated with non-specific symptoms until a physiological stress such as an illness precipitates an adrenal crisis. Morbidity and death associated with adrenal crisis is preventable but continues to be reported in children. There is a lack of consensus about the management of children at risk of AS. However, healthcare professionals need to develop an awareness and approach to keep these children safe. In this article, current knowledge of the risk factors, diagnosis and management of AS are reviewed while drawing attention to knowledge gaps and areas of controversy. Possible strategies to reduce the morbidity associated with this iatrogenic condition are provided for healthcare professionals.

Response to ‘Determining the utility of the 60-min cortisol measurement in the short Synacthen test’

2013 ◽  
Vol 80 (5) ◽  
pp. 766-767
Author(s):  
Carol Evans ◽  
Nadia El-Farhan ◽  
David Ducroq ◽  
Aled Rees
Keyword(s):  
Synacthen Test ◽  
Short Synacthen Test

Do we need 30 min cortisol measurement in the short synacthen test: a retrospective study

2019 ◽  
Vol 96 (1138) ◽  
pp. 467-472
Author(s):  
Rajeev Kumar ◽  
Peter Carr ◽  
Kimberley Moore ◽  
Zeeshan Rajput ◽  
Louise Ward ◽  
...  
Keyword(s):  
Retrospective Study ◽  
Adrenal Insufficiency ◽  
Late Response ◽  
Inadequate Response ◽  
Insufficient Response ◽  
Group A ◽  
Synacthen Test ◽  
Cortisol Levels ◽  
Group B ◽  
Short Synacthen Test

ObjectiveThe short synacthen test (SST) is widely used across the UK to assess adrenal reserve but there remains no consensus on the timing of cortisol sampling to help diagnose adrenal insufficiency. The main objective of our study was to see if both 30 and 60 min sample are required following administration of synacthen to investigate suspected adrenal insufficiency (AI).DesignThis was a single-centre retrospective study of 393 SSTs measuring 0, 30 and 60 min cortisol levels after administration of 250 µg of synacthen.Patients and methodsAll the SSTs for patients suspected of primary or secondary AI between April 2016 and October 2018 were included in this study. The tests were performed as per our hospital protocol. A post-adrenocorticotropic hormone (ACTH) cortisol response of 420 nmol/L at any time point was considered adequate to rule out AI. The data were analysed to ascertain the proportion of patients who achieved this level at 30 and/or 60 min.ResultsA total of 393 SST results were included in this study. Patients were divided into two groups depending on whether (group A) or not (group B) they were on steroids. Overall, a total of 313 (79.6%) subjects achieved cortisol level of ≥420 nmol/L at 30 and 60 min while 19 (4.8%) had late response (ie, insufficient 30 min cortisol levels, rising to ≥420 nmol/L at 60 min). Another 61 subjects (15.5%) showed insufficient response at both 30 and 60 min (ie, failed to achieved level of ≥420 nmol/L). Importantly, there was no patient in either group who had adequate response at 30 min and then failed at 60 min. Patients in group A were more likely to have inadequate response at both 30 and 60 min while patients in group B were more likely to have normal response at both time points.ConclusionsOur results suggest that about 5% of people undergoing SST may be inappropriately diagnosed as having AI (and subjected to long-term unnecessary steroid treatment) if the 60 min sample is not maintained. We suggest that 30 min sample does not add any additional diagnostic utility and can be omitted thus simplifying SST even further and saving on cost and resources. We propose that single measurement after 60 min of administration of synthetic ACTH is a sufficient screening test for AI.

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