Adrenal haemorrhage as a complication of COVID-19 infection

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.

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Pulmonary Thromboembolism in a Child with Sickle Cell Hemoglobin D Disease in the Setting of Acute Chest Syndrome

Case Reports in Pediatrics ◽

10.1155/2013/875683 ◽

2013 ◽

Vol 2013 ◽

pp. 1-3 ◽

Cited By ~ 1

Author(s):

Hazel Villanueva ◽

Sandeepkumar Kuril ◽

Jennifer Krajewski ◽

Aziza Sedrak

Keyword(s):

Pulmonary Artery ◽

Sickle Cell ◽

Pulmonary Thromboembolism ◽

Acute Chest Syndrome ◽

Standard Management ◽

Pulmonary Angiogram ◽

Right Pulmonary Artery ◽

Ct Pulmonary Angiogram ◽

Complete Thrombosis ◽

The Right

Introduction. Sickle cell hemoglobin D disease (HbSD) is a rare variant of sickle cell disease (SCD). Incidence of pulmonary thromboembolism (PE) and deep venous thrombosis (DVT) in children with HbSD is unknown. PE and DVT are known complications of SCD in adults but have not been reported in the literature in children with HbSD.Case Report. We are reporting a case of a 12-year-old boy with HbSD with acute chest syndrome (ACS) complicated by complete thrombosis of the branch of the right pulmonary artery and multiple small pulmonary artery emboli seen on computed tomography (CT) pulmonary angiogram and thrombosis of the right brachial vein seen on Doppler ultrasound. Our patient responded to treatment with anticoagulant therapy.Conclusion. There are no cases reported in children with HbSD disease presenting as ACS with pulmonary thromboembolism. We suggest that PE should be suspected in patients presenting with ACS who do not show improvement with standard management. CT pulmonary angiogram should be utilized for early diagnosis and appropriate management as there is no current protocol for management of PE/DVT in pediatric patients with SCD.

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Primary pulmonary angiosarcoma

BMJ Case Reports ◽

10.1136/bcr-2021-244578 ◽

2021 ◽

Vol 14 (11) ◽

pp. e244578

Author(s):

Muhammad Kashif Rana ◽

Owais Rahman ◽

Aiden O’Brien

Keyword(s):

Pulmonary Arteries ◽

Rare Type ◽

Pulmonary Artery Sarcoma ◽

Pulmonary Angiogram ◽

Primary Pulmonary Artery Sarcoma ◽

History Of ◽

Ct Pulmonary Angiogram ◽

The Right ◽

Specific Symptoms ◽

Large Primary

Primary pulmonary angiosarcoma is a rare type of malignant vascular tumour with poor prognosis. Diagnosis is often late due to non-specific symptoms and low clinical suspicion for angiosarcoma. A 72-year-old man presented to hospital with a 6-month history of mild progressive dyspnoea, with associated cough, episodes of presyncope and weight loss. CT pulmonary angiogram (CTPA) was reported as a large saddle pulmonary embolism extending into both the right and left pulmonary arteries. Further Multidisciplinary team meeting (MDM) discussion, and review of CTPA and subsequent investigations revealed a large primary pulmonary artery sarcoma which was later confirmed histology. The patient was referred to the cardiothoracic surgeons and underwent left radical pneumonectomy.

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Predictive Accuracy of Delta Cortisol on Recovery of Adrenal Function in Patients With Drug Induced Cushing’s Syndrome With Secondary Adrenal Insufficiency

Journal of the Endocrine Society ◽

10.1210/jendso/bvab048.182 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

pp. A91-A91

Author(s):

Bo Bo San

Keyword(s):

Cushing’S Syndrome ◽

Cushing Syndrome ◽

Serum Cortisol ◽

Cushing's Syndrome ◽

Adrenal Function ◽

Drug Induced ◽

Basal Serum ◽

Synacthen Test ◽

Short Synacthen Test

Abstract There is a growing concern upon the finding of many drug induced Cushing’s syndrome because of inadvertent use of glucocorticoids (GC) either prescribed or as alternative medicine in Myanmar. These patients are presenting with diversity of clinical problems ranging from hypertension, diabetes to acute adrenal crisis due to hypothalamic-pituitary-adrenal (HPA) axis suppression and secondary adrenal insufficiency (AI). The present study aimed to assess the delta cortisol (the degree of cortisol increments) during the first short Synacthen test (SST) as a factor predictive of adrenal function recovery in patients with drug induced Cushing’ syndrome with secondary AI and to determine the proportion of patients who recovered from AI within six-month follow-up. This was a hospital based prospective analytical study that enrolled a total of 52 patients with drug induced Cushing’s syndrome with secondary AI from January 2018 to June 2019. Secondary AI is defined by morning basal serum cortisol ≤ 400 nmol/L with Synacthen stimulated peak cortisol level ≤ 550 nmol/L and serum ACTH < 60 pg/ml. The follow-up SSTs were performed at three-month and six-month after first SST, and the patients with morning basal serum cortisol > 400 nmol/L (or) Synacthen stimulated peak serum cortisol > 550 nmol/L during follow-up SSTs are defined as recovered adrenal function group. In this study, a total of 52 patients were treated with modified regimen of physiological dose of prednisolone with tapering schedule or stress dose GC based on the basal serum cortisol levels up to six months. Among them, nearly half (n=25 / 48.1%) of the patients with drug induced Cushing’s syndrome with secondary AI achieved normal adrenal function within six-month follow-up. It was found that mean values for delta cortisol were not statistically significant between recovered and non-recovered groups, 118.6 nmol/L (SD 72.3) and 97.2 nmol/L (SD 64.2) respectively. The delta cortisol during the first SST could not predict strongly (AUC - 0.6, 95% CI - 0.44 to 0.76, P = 0.2) the recovery of adrenal function in patients with drug induced Cushing’s syndrome with secondary AI and it was inconsistent with previous studies. The older age of the patients, oral route of administration of drugs causing Cushing’s syndrome and comorbid hypertension were found to be more significant in the non-recovered group. In conclusion, the present study did not support the evidence that the delta cortisol during the first SST could predict adrenal function recovery in patients with drug induced Cushing’ syndrome with secondary AI. Reference: (1) Baek et al., 2016; Recovery of Adrenal Function in Patients with Glucocorticoids Induced Secondary AI. Endocrinol Metab.31, pp. 153–160. (2) Pofi et al., 2018; The Short Synacthen Test Can Be Used to Predict Recovery of HPA Axis Function. J Clin Endocrinol Metab.103(8), pp. 3050–3059.

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780 Appearing and disappearing right-heart thrombus: a case reporto in COVID-19 patient

European Heart Journal Supplements ◽

10.1093/eurheartj/suab135.011 ◽

2021 ◽

Vol 23 (Supplement_G) ◽

Author(s):

Giacomo Campi ◽

Martina Finocchi ◽

Nicolas Palagano ◽

Emanuela Calcagno ◽

Alessandra Pesci ◽

...

Keyword(s):

Venous Thromboembolism ◽

Right Ventricle ◽

Thrombus Formation ◽

Nasopharyngeal Swab ◽

Cardiac Ultrasound ◽

Free Wall ◽

Pulmonary Angiogram ◽

Right Ventricle Free Wall ◽

Ct Pulmonary Angiogram ◽

The Right

Abstract Aims Venous thromboembolism represents frequent complication of patients with severe COVID-19 disease. Several reports about atypical thrombosis are described, rarely it has been described a right venticular thrombus during the course of infection. We report a case of right endoventricular thrombosis in a patient with SARS-Cov-2 pneumonia. Methods and results A 58-year-old man was admitted to our ward for severe respiratory failure in interstitial pneumonia. The nasopharyngeal swab for COVID-19 resulted positive. Steroids and prophylaxis with LMWH were started, associated to CPAP to maintain good gas exchange. During hospitalization a venous ECD was performed with evidence of left popliteal thrombosis despite the therapy. d-Dimer was 4463 ng/ml. A new onset AF was documented at the telemetry, without troponin elevation. A cardiac ultrasound was performed showing a right endoventricular lesion of 1.8 cm adhering to the free wall of the right ventricle. A CT-pulmonary angiogram (CTPA) resulted negative for pulmonary embolism and confirmed suspected right ventricular thrombus. Treatment with fondaparinux 7.5 mg was started. After 10 days, cardiac ultrasound shown complete resolution of thrombosis, and CT confirmed the disappearing of the mass. Dabigatran 150 mg twice/day was started. Patient clinically improved and he was discharged after 20 days of hospitalization. Conclusions SARS-CoV-2 infection may cause inflammation with cytokine storm and hypercoagulability leading to venous thromboembolism. Atypical thrombus formation was reported, including right-ventricle free wall. Early caridac ultrasound was critical to make diagnosis and starting prompt treatment, therefore routine cardiac ultrasound is mandatory in severe COVID-19 patients.

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Migration of the Anterior Spinal Rod to the Right Thigh, a Rare Complication of Anterior Spinal Instrumentations: A Case Report and a Literature Review

Case Reports in Orthopedics ◽

10.1155/2015/532412 ◽

2015 ◽

Vol 2015 ◽

pp. 1-4 ◽

Cited By ~ 1

Author(s):

Camino Willhuber Gaston ◽

Taype Zamboni Danilo ◽

Carabelli Guido ◽

Barla Jorge ◽

Sancineto Carlos

Keyword(s):

Rare Complication ◽

Spinal Instrumentation ◽

Unusual Complication ◽

Anterior Fusion ◽

Long Term Follow Up ◽

The Right ◽

Rod Migration ◽

Surgical Treatments

Posterior and anterior fusion procedures with instrumentation are well-known surgical treatments for scoliosis. Rod migration has been described as unusual complication in anterior spinal instrumentations; migration beyond pelvis is a rare complication. A 32-year-old female presented to the consultant with right thigh pain, rod migration was diagnosed, rod extraction by minimal approach was performed, and spinal instrumentation after nonunion diagnosis was underwent. A rod migration case to the right thigh is presented; this uncommon complication of spinal instrumentation should be ruled out as unusual cause of sudden pain without any other suspicions, and long-term follow-up is important to prevent and diagnose this problem.

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Pulmonary mucormycosis causing a mycotic pulmonary artery aneurysm

Asian Cardiovascular and Thoracic Annals ◽

10.1177/0218492321998495 ◽

2021 ◽

pp. 021849232199849

Author(s):

Richard Saldanha ◽

Ravi Ghatanatti ◽

Mohan D Gan ◽

Kiran Kurkure ◽

Gautam Suresh ◽

...

Keyword(s):

Pulmonary Artery ◽

Artery Aneurysm ◽

High Morbidity ◽

Pulmonary Artery Aneurysm ◽

Pulmonary Mucormycosis ◽

Pulmonary Angiogram ◽

Ct Pulmonary Angiogram ◽

Pulmonary Artery Aneurysms ◽

The Right ◽

Very High

Mycotic pulmonary artery aneurysms requiring pneumonectomy are extremely rare. We present a severely breathless immunocompromised diabetic middle-aged female patient. CT pulmonary angiogram revealed a giant pulmonary artery aneurysm with impending rupture in the right lung. We did an emergency right pneumonectomy under cardiopulmonary bypass support. Histopathology report of the lung specimen confirmed mucormycosis. She received amphotericin B after the procedure. The patient had a prolonged postoperative hospital stay and succumbed to sepsis. Mycotic pulmonary artery aneurysm portends very high morbidity and mortality in immunocompromised patients.

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Feasibility of Detecting Pulmonary Embolism Using Noncontrast MRI

ISRN Radiology ◽

10.5402/2013/729271 ◽

2013 ◽

Vol 2013 ◽

pp. 1-5 ◽

Cited By ~ 4

Author(s):

C. S. Mudge ◽

T. T. Healey ◽

M. K. Atalay ◽

J. A. Pezzullo

Keyword(s):

Pulmonary Embolism ◽

Cardiac Mri ◽

Imaging Techniques ◽

Pulmonary Arteries ◽

Pulmonary Emboli ◽

Pulmonary Angiogram ◽

Mri Protocol ◽

Ct Pulmonary Angiogram ◽

Magnetic Resonance Imaging Techniques ◽

The Right

Purpose. The purpose of this study was to evaluate the feasibility of detecting pulmonary emboli utilizing noncontrast magnetic resonance imaging techniques in patients with known pulmonary embolism. Materials and Methods. Eleven patients were enrolled in a study to evaluate right ventricular function by cardiac MRI in patients diagnosed with acute pulmonary embolism on CT pulmonary angiogram. Cardiac MRI was performed as soon as possible following pulmonary embolism detection. Two independent observers reviewed the precontrast portion of each MRI, scoring right, left, and lobar arteries as positive or negative for PE. The CTs were reviewed and interpreted in the same manner. Results. MRI was obtained on average of 40 hours after the CT. Forty-eight vessels were affected by PE on CT, 69% of which were identified on MRI. All eight pulmonary emboli located in the right or left pulmonary arteries were detected on MRI. Of the 15 pulmonary emboli that were not detected on MRI, 7 were subsegmental, 6 were segmental, and 2 were located in a branch not included in the MRI field of view. Conclusions. Most pulmonary emboli detected on CT were identified on noncontrast MRI, even though our MRI protocol was not optimized for pulmonary artery visualization.

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Pulmonary embolism with coexistent incidental pulmonary cement embolism post vertebroplasty

BMJ Case Reports ◽

10.1136/bcr-2020-237449 ◽

2021 ◽

Vol 14 (3) ◽

pp. e237449

Author(s):

James Ross ◽

Robin Bhatia ◽

Tom Hyde ◽

Giles Dixon

Keyword(s):

Thrombus Formation ◽

Main Pulmonary Artery ◽

Sudden Onset ◽

Incidence Rates ◽

Lytic Lesion ◽

Pleuritic Chest Pain ◽

Pulmonary Angiogram ◽

Cement Embolism ◽

Ct Pulmonary Angiogram ◽

The Right

A 46-year-old woman presented with sudden onset of shortness of breath and pleuritic chest pain. A CT pulmonary angiogram identified a 5 cm cement pulmonary embolus within the right main pulmonary artery with a surrounding thrombus. She had undergone an L4 vertebroplasty 3 years prior to presentation for a benign lytic lesion. Cement embolus is a known complication of cement vertebroplasty with incidence rates of approximately 0.9%. Management is usually conservative and associated morbidity and mortality rates are low. It is not known whether a previous cement embolus could provide a nidus for thrombus formation.

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

BMJ Case Reports ◽

10.1136/bcr-2020-238628 ◽

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.

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Patients with markedly elevated D-dimer who do not have pulmonary embolism

Postgraduate Medical Journal ◽

10.1136/postgradmedj-2019-137123 ◽

2020 ◽

pp. postgradmedj-2019-137123

Author(s):

Jeren Lim ◽

Calum Cardle ◽

Chris Isles

Keyword(s):

Pulmonary Embolism ◽

Aortic Dissection ◽

Inclusion Criteria ◽

Kaplan Meier ◽

Pulmonary Angiogram ◽

Ct Pulmonary Angiogram ◽

Very High ◽

D Dimer ◽

Active Cancer

ObjectiveTo determine the cause of a markedly raised D-dimer among patients in whom a diagnosis of pulmonary embolism (PE) has been excluded by CT pulmonary angiogram (CTPA) with particular reference to new cases of cancer and aortic dissection.MethodsOne thousand consecutive patients, suspected of PE, who had undergone CTPA and for whom a D-dimer had been requested, were seen between 2012 and 2016. Retrospectively we examined the case records of all those in the top quintile of the D-dimer distribution whose CTPA was negative for PE. D-dimer in the top quintile ranged from 7.5 to 260 times upper limit normal.ResultsEighty-five patients fulfilled our inclusion criteria. The likely causes of their very high D-dimer were infection (n=35, 41.2%), cardiovascular disease (n=12, 14.1% including two patients with previously undiagnosed aortic dissection), surgery or trauma (n=12, 14.1%), new or active cancer (n=9, 10.6% comprising six new cancers and three patients with cancers diagnosed previously that were considered to be active) and miscellaneous causes (n=17, 20.0%). Thirty-five patients (43.5%) died over a 2-year follow-up. Kaplan-Meier survival analysis showed poorer outcomes for patients with new or active cancer, when compared with those with no known cancer (p<0.001).ConclusionsWe have shown that a small proportion of patients suspected of PE whose D-dimers are markedly elevated have diagnoses we would not want to miss including previously unsuspected cancer and aortic dissection. Further studies will be required to define the optimal workup of patients with extremely high D-dimer who do not have venous thromboembolism

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