Document Detail

Acute adrenal insufficiency following arthroplasty: a case report and review of the literature.
Jump to Full Text
MedLine Citation:
PMID:  24028157     Owner:  NLM     Status:  Publisher    
Abstract/OtherAbstract:
BACKGROUND: Acute adrenal insufficiency is a potentially lethal condition rarely caused by bilateral adrenal haemorrhage due to heparin use. Most of the times, it is difficult to establish the diagnosis, as symptoms are not specific. Few cases have been reported in the literature.
CASE PRESENTATION: A 52-year-old Caucasian woman presented with abdominal pain, vomiting and weakness nine days after arthroplasty and heparin use. Hyperkalemia, low cortisol and high adrenocorticotropic hormone levels were found, indicating adrenal insufficiency. Magnetic resonance imaging of the upper abdomen was compatible with preceding adrenal haemorrhage. Hydrocortisone and fludrocortisone were administered. Review of the literature revealed 36 cases of postoperative adrenal haemorrhage which are presented briefly.
CONCLUSION: Postoperative acute adrenal insufficiency due to haemorrhage is a rare condition. If patients are treated based on clinical suspicion, they have good chances to survive. Hydrocortisone is given permanently in the majority of the patients.
Authors:
Stylianos Mandanas; Maria Boudina; Alexandra Chrisoulidou; Katerina Xinou; Efterpi Margaritidou; Spyros Gerou; Kalliopi Pazaitou-Panayiotou
Related Documents :
16649457 - Trauma related to sexual assault in calabar, south eastern nigeria.
25133197 - Clinical, laboratory, and therapeutic analyses of 21 patients with neonatal thrombosis ...
20022197 - Two cases of penetrating abdominal injury from needlefish impalement.
117637 - Epidemiology of waterskiing injuries.
16753607 - Placental mesenchymal dysplasia is associated with high rates of intrauterine growth re...
553367 - "bell-shaped ureter," a radiographic sign of antegrade intussusception.
Publication Detail:
Type:  JOURNAL ARTICLE     Date:  2013-9-12
Journal Detail:
Title:  BMC research notes     Volume:  6     ISSN:  1756-0500     ISO Abbreviation:  BMC Res Notes     Publication Date:  2013 Sep 
Date Detail:
Created Date:  2013-9-13     Completed Date:  -     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  101462768     Medline TA:  BMC Res Notes     Country:  -    
Other Details:
Languages:  ENG     Pagination:  370     Citation Subset:  -    
Export Citation:
APA/MLA Format     Download EndNote     Download BibTex
MeSH Terms
Descriptor/Qualifier:

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

Full Text
Journal Information
Journal ID (nlm-ta): BMC Res Notes
Journal ID (iso-abbrev): BMC Res Notes
ISSN: 1756-0500
Publisher: BioMed Central
Article Information
Download PDF
Copyright © 2013 Mandanas et al.; licensee BioMed Central Ltd.
open-access:
Received Day: 5 Month: 7 Year: 2013
Accepted Day: 9 Month: 9 Year: 2013
collection publication date: Year: 2013
Electronic publication date: Day: 12 Month: 9 Year: 2013
Volume: 6First Page: 370 Last Page: 370
PubMed Id: 24028157
ID: 3847353
Publisher Id: 1756-0500-6-370
DOI: 10.1186/1756-0500-6-370

Acute adrenal insufficiency following arthroplasty: a case report and review of the literature
Stylianos Mandanas1 Email: smandanas@yahoo.gr
Maria Boudina1 Email: mariaboudina@gmail.com
Alexandra Chrisoulidou1 Email: alexri@otenet.gr
Katerina Xinou1 Email: katxinou@otenet.gr
Efterpi Margaritidou1 Email: efimargaritidou@gmail.com
Spyros Gerou1 Email: sgerou@otenet.gr
Kalliopi Pazaitou-Panayiotou1 Email: kpazaitoupanayiotou@gmail.com
1Department of Endocrinology, Theagenion Cancer Hospital, Al. Simeonidi st, Thessaloniki 54007, Greece

Background

Acute adrenal failure (AAF) is a potentially life-threatening complication presenting with non-specific symptoms as abdominal pain, nausea, fever, tachycardia, hypotension and lethargy [1]. However, hyponatremia and hyperkalemia as indicators of adrenal insufficiency should be evaluated very thoroughly [2].

AAF may occur in patients with previously undiagnosed primary adrenal insufficiency and sometimes after bilateral adrenal infarction or postoperative haemorrhage in otherwise healthy individuals [1]. The postoperative period carries a high risk for haemorrhage, as platelet consumption may lead to bleeding in vital organs, independently of anticoagulant administration. Additionally, the use of heparin represents an independent risk factor that predisposes to haemorrhage [3]. Injuries during procedures such as extracorporeal shock-wave lithotripsy or electroconvulsive therapy [4,5] or use of certain materials and techniques may also predispose to coagulopathy and haemorrhage [6]. Moreover, hypothermia itself may play an important role in bleeding [6]. As signs and symptoms are not specific, they may easily lead to wrong diagnosis, such as postoperative septic shock or inflammation.

Total hip arthroplasty is a common surgical procedure associated with deep venous thrombosis and pulmonary embolism that are prevented by the use of anticoagulants [7,8]. The extensive use of anticoagulants in these operations explains the fact that bilateral adrenal haemorrhage is more often observed after knee or hip arthroplasty. However, orthopaedic surgery is probably associated with risk factors (other than anticoagulants) which lead to haemorrhage [9].

The use of low molecular weight heparin (LMWH) to avoid postoperative thromboembolic events can induce thrombocytopenia (heparin-induced thrombocytopenia [HIT]) and may lead to bilateral adrenal haemorrhage [2]. A pre-test clinical score (including thrombocytopenia, timing of platelet count fall, thrombosis, presence of other causes for thrombocytopenia, the so-called 4 T's) has been developed to establish the clinical suspicion of HIT [10], while heparin-platelet factor 4-immunoglobulin G (IgG) (PF4-IgG) antibodies and 14C-serotonin release assay are useful diagnostic tests [2].

The incidence of bilateral adrenal haemorrhage is estimated to be around 4.7–6.2 cases per million habitants in developed countries, but the prevalence is much higher in hospitalized patients, arising to 1.1% of them [11,12]. There are difficulties in establishing an early diagnosis of the disease [13] and adrenal haemorrhage is usually a post-mortem finding during autopsy performed to unravel the cause of death.

In addition to the elusive clinical presentation, imaging may also be deceiving: the enlarged haemorrhagic adrenals may be misdiagnosed as neoplastic masses, with irregular margins, though maintain their adreniform shape. Acute and subacute adrenal haemorrhage show high attenuation (50–90 HU) at unenhanced computed tomography (CT), without enhancement following intravenous (IV) contrast. In doubtful cases, decreased density and size of the adrenals during follow-up as well as the presence of calcifications may be extremely useful to confirm the diagnosis. Magnetic resonance imaging (MRI) is the most sensitive and specific imaging modality to confirm adrenal haemorrhage. Like CT, the appearance of adrenal haemorrhage on MRI also depends on the progression of the bleeding. The most characteristic sign on MRI is the low signal ring on T2 sequences during the chronic phase [14].

The aim of the present work was a) to present a case of acute adrenal insufficiency caused by bilateral adrenal haemorrhage observed after arthroplasty and b) to summarize the published data regarding this rare and interesting clinical entity.

Computerized literature search was performed in the PubMed electronic database. The original query provided 71 possibly relevant articles. Furthermore, 10 articles were retrieved after searching the “Related Articles” link and the references. Of these, 34 were finally selected (including 36 case reports), whereas the remaining 47 articles were excluded for the following reasons: spontaneous bilateral adrenal haemorrhage without apparent cause (n=9); concurrent diseases (n=7); bilateral adrenal haemorrhage due to heparin for other reason, not postoperatively (n=27); article in Japanese (n=1); reviews and letters to the editor (n=3).

In summary, 36 cases of postoperative bilateral adrenal haemorrhage have been documented. Mean age of patients during haemorrhage was 65.2 years (range 44–83) and there was no particular sex distribution. Abdominal pain, fever, vomiting and hypotension were the main symptoms at presentation, usually occurring between first and second week after surgery. Hyponatremia and hyperkalemia were the most common laboratory findings. In 27 out of 36 patients, diagnosis was made by CT scan, in two by abdominal ultrasound and in one by exploratory laparotomy. In four patients the diagnosis was confirmed after their death during autopsy and in two cases the imaging was not described. Nine patients succumbed to adrenal insufficiency.

Patients’ clinical characteristics and diagnostic methods are summarized in Tables 1 and 2. Reported cases are divided into two groups: the first includes 21 patients with adrenal insufficiency after orthopaedic surgery (Table 1) and the second reports 15 patients with adrenal insufficiency after any other surgery (Table 2).


Case presentation
Patients’ history

A 52-year-old Caucasian woman, mother of two children, underwent right hip arthroplasty and was administered LMWH (enoxaparin 8,000 IU per day) for seven days in order to prevent thromboembolic events. Arthroplasty was successfully completed without intraoperative or early postoperative complications, except for a fall in platelet count from 214,000/μL to 116,000/μL. Haemoglobin and white blood cell count were normal. The patient was discharged from the hospital in good condition without any sign or symptom of haemorrhage, thromboembolism or infection.

9th postoperative day, emergency department

On postoperative day 9, she presented in the emergency department complaining of abdominal pain, vomiting and weakness. She was dehydrated and tachycardic (105 beats per minute). Decreased skin turgor and low blood pressure (90/60mm Hg) were observed. Biochemical exams indicated hyponatremia (128mmol/L, normal range 136–145) and hyperkalemia (5.97mmol/L, normal range 3.5-5.1), normal serum glucose levels, as well as normal kidney and liver function. The patient was afebrile and the wound healed satisfactory. The administration of isotonic solutions was decided but the patient responded poorly. Intravenous use of dopamine was added thereafter, resulting in slight improvement of clinical symptoms, mainly vomiting and arterial blood pressure. As the abdominal pain was persistent, the patient underwent abdominal CT which was indicative of “bilateral adrenal adenomas”. Due to this finding, the patient was referred to our department for further evaluation.

Referral to the endocrinology department

Considering the clinical signs of dehydration and the presence of hyperkalemia (5.72mmol/L, normal range 3.5-5.1) and hyponatremia (130mmol/L, normal range 136–145), adrenal insufficiency was suspected. Cortisol levels were measured and found to be very low (cortisol 40nmol/l, normal range 70-250nmol/l). A 250-μg adrenocorticotropic hormone (ACTH) stimulation test (Synacthen test) was performed for further evaluation; no increase in cortisol was observed confirming the diagnosis of primary adrenal insufficiency (basal cortisol equal to 32.9nmol/l, 30 and 60 min after Synacthen equal to 34nmol/l and 32.1nmol/l respectively, normal range 70-250nmol/l). ACTH levels were very high (1763.4pg/ml, normal range 9–52). MRI of the upper abdomen showed the presence of bilateral adrenal “lesions” with greatest dimension 2.3cm on the right and 2.5cm on the left. On T2 weighted-images the above mentioned findings had high signal intensity with a low signal intensity ring along the periphery compatible with the presence of haemosiderin consequence of previous haemorrhage and chronic hematomas (Figure 1). No signal drop-off on in- and out- of phase images and no significant enhancement following iv contrast was depicted.

Diagnostic evaluation and therapy

Considering the variety of causes that could trigger bilateral adrenal haemorrhage in accordance with the medical history of the patient, traumatic injury, burns or pregnancy were ruled out [13]. Furthermore, she was afebrile without any clinical signs of septic shock. Antiphospholipid syndrome was excluded due to the absence of vascular thrombosis and the history of two normal deliveries. Based on the fact that the patient had received LMWH postoperatively, haemorrhage was considered to be the cause of adrenal failure. Heparin-PF4-IgG antibodies (measured by enzyme-linked immunosorbent assay [ELISA]) were negative. Moreover, the low pretest clinical score for HIT (total 2 points, 1 point from thrombocytopenia and 1 point from surgery) in the patient was correlated with high- negative predictive value for heparin induced adrenal haemorrhage [10].

Replacement therapy with hydrocortisone and fludrocortisone was started. Three months later, ACTH levels fell to 397pg/ml. Adrenal MRI showed that the lesions had decreased in size and had homogeneous low signal on T2 weighted images, findings consistent with the evolution of hematomas (Figure 2). The oral replacement with hydrocortisone and fludrocortisone remains until the present time.


Conclusions

Bilateral adrenal haemorrhage is a rare disease which can follow major surgical operations. It should be suspected in patients presenting with fever, abdominal pain, confusion and hemodynamic collapse not responding to standard medical treatment [31]. The increased incidence after orthopaedic surgery, the association with anticoagulants use and the great mortality in misdiagnosed cases should keep physicians alerted.


Consent

Written informed consent was obtained from the patient for publication of this Case Report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Abbreviations

AAF: Acute adrenal failure; LMWH: Low molecular weight heparin; HIT: Heparin induced thrombocytopenia; IgG: Immunoglobulin G; PF4-IgG: Platelet factor 4- immunoglobulin G; CT: Computed tomography; IV: Intravenous; MRI: Magnetic resonance imaging; ACTH: Adrenocorticotropic hormone; ELISA: Enzyme-linked immunosorbent assay.


Competing interests

The authors declare that they have no competing interests.


Authors’ contributions

SM and MB reviewed the literature and prepared the draft. KX performed and discussed imaging. EM collected patients’ clinical data. SG performed the immunoassay. AC and KPP conceived the idea and made the amendments of the manuscript. All authors read and approved the final manuscript.


Disclosure statement

The authors have nothing to disclose.


References
Bouillon R,Acute adrenal insufficiencyEndocrinol Metab Clin North AmYear: 2006676777510.1016/j.ecl.2006.09.00417127145
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 thrombocytopeniaCrit Care MedYear: 2011683383810.1097/CCM.0b013e318206d0eb21242799
Chang JC,Review: Postoperative thrombocytopenia: with etiologic, diagnostic, and therapeutic considerationAm J Med SciYear: 199669610510.1097/00000441-199602000-000098615383
Donald IP,Freeman CP,Adrenal hemorrhagic necrosis following electroconvulsive therapyLancetYear: 198262776124705
Lai YL,Chang WC,Huang HH,Obscure abdominal pain in a 55-year-old man. Diagnosis: Intra-abdominal hemorrhage with adrenal hematoma. GastroenterologyYear: 2010638710.1053/j.gastro.2009.09.06620600068
McKenna R,Abnormal coagulation in the postoperative period contributing to excessive bleedingMed Clin North AmYear: 200161277131010.1016/S0025-7125(05)70378-311565500
Geerts WH,Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)ChestYear: 20086Suppl 6381453
Schuchmann JA,Friedman PA,Bilateral adrenal hemorrhage: an unusual complication after bilateral total knee arthroplastyAm J Phys Med RehabilYear: 2005689990310.1097/01.phm.0000176351.97994.7316244529
Oberweis BS,Nukala S,Rosenberg A,Guo Y,Stuchin S,Radford MJ,Berger JS,Thrombotic and bleeding complications after orthopedic surgeryAm Heart JYear: 2013642743310.1016/j.ahj.2012.11.00523453114
Lo GK,Juhl D,Warkentin TE,Sigouin CS,Eichler P,Greinacher A,Evaluation of pretest clinical score (4 T's) for the diagnosis of heparin-induced thrombocytopenia in two clinical settingsJ Thromb HaemostYear: 2006675976510.1111/j.1538-7836.2006.01787.x16634744
Bharucha T,Broderick C,Easom N,Roberts C,Moore D,Bilateral adrenal haemorrhage presenting as epigastric and back painJRSM Short RepYear: 201261510.1258/shorts.2011.01110722479678
Vella A,Nippoldt TB,Morris JC 3rd,Adrenal hemorrhage: a 25-year experience at the Mayo ClinicMayo Clin ProcYear: 2001616116811213304
Arlt W,Allolio B,Adrenal insufficiencyLancetYear: 200361881189310.1016/S0140-6736(03)13492-712788587
Wah TM,Guthrie JA,Joyce AD,De la Rosette JJMCH, Manyak MJ, Harisinghani MG, Wijkstra HCross-Sectional Imaging of adrenal massesImaging in Oncological UrologyYear: 2009London: Springer527
Findling JW,Korducki JM,Lahiri PK,Miller DD,Raff H,Bilateral adrenal hemorrhage associated with heparin-induced thrombocytopeniaWis Med JYear: 1987627293564517
Delhumeau A,Houet JF,Bourrier P,Bukowski JG,Granry JC,Heparin-induced thrombocytopenia complicated by hematoma of the adrenal glands and acute adrenal insufficiencyAnn Fr Anesth ReanimYear: 1989665665810.1016/S0750-7658(89)80183-22633663
Ernest D,Fisher MM,Heparin-induced thrombocytopaenia complicated by bilateral adrenal haemorrhageIntensive Care MedYear: 1991623824010.1007/BF017098851744311
Souied F,Pourriat JL,Le Roux G,Hoang P,Kemeny JL,Cupa M,Adrenal hemorrhagic necrosis related to heparin-associated thrombocytopeniaCrit Care MedYear: 1991629729910.1097/00003246-199102000-000331842892
Bleasel JF,Rasko JE,Rickard KA,Richards G,Acute adrenal insufficiency secondary to heparin-induced thrombocytopenia-thrombosis syndromeMed J AustYear: 199261921931635495
Hardwicke MB,Kisly A,Prophylactic subcutaneous heparin therapy as a cause of bilateral adrenal hemorrhageArch Intern MedYear: 1992684584710.1001/archinte.1992.004001601330261558445
Delhumeau A,Moreau X,Chapotte C,Houi N,Bigorgne JC,Heparin-associated thrombocytopenia syndrome: an underestimated etiology of adrenal hemorrhageIntensive Care MedYear: 1993647547710.1007/BF017110918294632
Santonastaso M,Bovo P,Colaceci R,Corbanese U,Ruga P,Acute adrenal failure due to adrenal hemorrhagic necrosis secondary to heparin-induced thrombocytopeniaRecenti Prog MedYear: 199366876908235035
Ries MD,Guiney W Jr,Lynch F,Fatal massive adrenal hemorrhage after bilateral total knee arthroplastyJ ArthroplastyYear: 1994655956210.1016/0883-5403(94)90106-67807117
Cozzolino D,Peerzada J,Heaney JA,Adrenal insufficiency from bilateral adrenal hemorrhage after total knee replacement surgeryUrologyYear: 1997612512710.1016/S0090-4295(97)00102-79218034
Rowland CH,Woodford PA,De Lisle-Hammond J,Nair B,Heparin-induced thrombocytopenia-thrombosis syndrome and bilateral adrenal haemorrhage after prophylactic heparin useAust N Z J MedYear: 1999674174210.1111/j.1445-5994.1999.tb01626.x10630659
Caubet O,Pillet O,Cherifi A,Mayet T,Castaing Y,Favarel Garrigues JC,Acute adrenal insufficiency due to bilateral adrenal hematoma following severe thrombopenia induced by low-molecular-weight heparinPresse MedYear: 199961010101210379347
Scheffold N,Schöngart H,Berentelg J,Prager P,Cyran J,Rare complication of a heparin-induced thrombocytopenia type IIDtsch Med WochenschrYear: 2001632933310.1055/s-2001-1209411305201
LaBan MM,Whitmore CE,Taylor RS,Bilateral adrenal hemorrhage after anticoagulation prophylaxis for bilateral knee arthroplastyAm J Phys Med RehabilYear: 2003641842012704285
Kurtz LE,Yang S,Bilateral adrenal hemorrhage associated with heparin induced thrombocytopeniaAm J HematolYear: 2007649349410.1002/ajh.2088417266058
Mongardon N,Bruneel F,Henry Lagarrigue M,Legriel S,Revault D'Allonnes L,Guezennec P,Troche G,Bedos JP,Shock during heparin-induced thrombocytopenia: look for adrenal insufficiencyIntensive Care MedYear: 2007654754810.1007/s00134-006-0487-917186288
Thota R,Porter J,Ganti AK,Peters E,Hemodynamic collapse following bilateral knee arthroplasty: a mysterious caseJ Thromb ThrombolysisYear: 201263510.1007/s11239-011-0640-321938456
Chow VW,Abnousi F,Huddleston JI,Lin LH,Heparin-induced thrombocytopenia after total knee arthroplasty, with subsequent adrenal hemorrhageJ ArthroplastyYear: 201261518 1413.e. 10.1016/j.arth.2011.02.01621414743
Steer M,Fromm D,Recognition of adrenal insufficiency in the postoperative patientAm J SurgYear: 1980644344610.1016/0002-9610(80)90312-86244751
Jacobson SA,Blute RD Jr,Green DF,McPhedran P,Weiss RM,Lytton B,Acute adrenal insufficiency as a complication of urological surgeryJ UrolYear: 198663373403944871
Miller EH,Woldenberg DH,Gittler RD,Zumoff B,Bilateral adrenal hemorrhage following surgeryN Y State J MedYear: 198666516533468384
Homcy CJ,Southern JF,Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 49–1989. A 71-year-old man with thrombocytopenia and hypotension after resection of a colonic carcinomaN Engl J MedYear: 198961595160310.1056/NEJM1989120732123082586555
Ting W,Nosher JL,Scholz PM,Spotnitz AJ,Bilateral adrenal hemorrhage after an open heart operationAnn Thorac SurgYear: 1992635735810.1016/0003-4975(92)91401-T1637233
Leschi JP,Goëau-Brissonnière O,Coggia M,Chiche L,Heparin-related thrombocytopenia and adrenal hemorrhagic necrosis following aortic surgeryAnn Vasc SurgYear: 1994650650810.1007/BF021330737811590
Belmore DJ,Walters DN,Bilateral adrenal hemorrhage following laparoscopic cholecystectomySurg EndoscYear: 199569199208525450
Scheiwiller A,Morel P,Soravia C,Bilateral adrenal gland hemorrhage after anterior deep rectum resection. Case report with review of the literatureChirurgYear: 2002662863210.1007/s00104-001-0403-312149950
Sousa Escandón A,Mateos A,Sánchez F,González A,García R,Pérez J,Pulpeiro JR,Uribarri C,Massive bilateral adrenal hemorrhage after conservative tumor surgery in the isthmus of a horseshoe kidneyActas Urol EspYear: 2002642042410.1016/S0210-4806(02)72805-212189738
Bakaeen FG,Walkes JC,Reardon MJ,Heparin-induced thrombocytopenia associated with bilateral adrenal hemorrhage after coronary artery bypass surgeryAnn Thorac SurgYear: 200561388139010.1016/j.athoracsur.2003.09.10815797086
Gutenberg A,Lange B,Gunawan B,Larsen J,Brück W,Rohde V,Verheggen R,Spontaneous adrenal hemorrhage: a little-known complication of intracranial tumor surgery. Case reportJ NeurosurgYear: 200761086108810.3171/jns.2007.106.6.108617564184
Munoz Corsini L,Delgado Arnaiz C,Garcia Del Valle S,Reboto Cortes P,Lopez Del Castillo A,Postoperative bilateral adrenal hemorrhage: correlation between clinical and radiological signsJ Clin AnesthYear: 2008660560810.1016/j.jclinane.2008.05.02419100934
Peel N,Whitelaw SC,Bilateral adrenal haemorrhage following right hemicolectomyInt J Colorectal DisYear: 2011668168210.1007/s00384-010-1035-120680302
Balsach Solé A,Oms Bernat LM,Garrido Romero M,Mato Ruiz R,Sala-Pedrós J,Bilateral adrenal haemorrhage after cephalic duodenopancreatectomyCir EspYear: 20126565710.1016/j.ciresp.2010.06.01421411065

Figures

[Figure ID: F1]
Figure 1 

Abdominal magnetic resonance imaging obtained 15 days after surgery. Axial (A) T2 weighted image with fat suppression, coronal (B) T2 weighted image, in and out of phase axial (C, D) T1 images, axial (E, F) T1 weighted images with fat saturation before and after contrast administration, coronal (G) T2-weighted image. Bilateral adrenal lesions showing high signal both on T1-weighted (E) and on T2-weighted images (A, B), and low signal rim on T2-weighted images (A, B), representing haemosiderin. The lesions do not show any signal drop-off on T1 in- (C) and out- of phase images (D). After intravenous contrast administration (F) no enhancement is depicted. These findings are consistent with chronic adrenal hematomas. Note the signal void in the right pelvis due to the presence of a metallic right hip prosthesis.



[Figure ID: F2]
Figure 2 

Abdominal magnetic resonance imaging obtained 3.5 months after surgery. Axial (A, B) and coronal (C) T2-weighted images showing a decrease in size and a change of signal of the bilateral adrenal hematomas. The lesions now have homogeneous low signal, due to haemosiderin.



Tables
[TableWrap ID: T1] Table 1 

Adrenal insufficiency after orthopaedic surgery


Cases Author Country Age Sex Type of surgery Diagnosis Symptoms Biochemical exams
1
Findling et al., 1987 [15]
USA
44
M
unspecified
CT
abdominal pain, vomiting, hypotension
hyponatremia, hyperkalemia
2
Delhumeau et al., 1989 [16]
France
76
F
total hip arthroplasty
abdominal ultrasound
abdominal pain, fever, hypotension, altered consciousness
hyponatremia, natriuresis, thrombocytopenia
3
74
M
tibial osteosynthesis
not done
abdominal pain, fever, hypotension, shock, altered consciousness
hyponatremia, thrombocytopenia
4
62
M
tibial osteosynthesis
CT
abdominal pain, asthenia, nausea
hyponatremia, thrombocytopenia
5
Ernest and Fischer, 1991 [17]
Australia
68
F
total hip arthroplasty
CT
fever, hypotension
hyponatremia, hyperkalemia
6
Souied et al., 1991 [18]
France
63
F
total hip arthroplasty
CT
fever, hypotension
hyponatremia, hyperkalemia
7
Bleasel et al., 1992 [19]
Australia
69
F
total knee arthroplasty
CT
fever, nausea, vomiting, abdominal pain, hypotension
hyponatremia, hyperkalemia
8
Hardwicke and Kisly, 1992 [20]
USA
63
F
bilateral total knee arthroplasty
CT
fever, nausea, anorexia, vomiting, abdominal pain, confusion, feeling of illness, hypotension
anemia, hyponatremia, hyperkalemia
9
Delhumeau et al., 1993 [21]
France
74
M
total hip arthroplasty, thrombectomy of both limbs due to bilateral arterial thrombosis
CT
abdominal pain, fever, hypotension, abdominal tenderness
hyponatremia, hyperkalemia
10
Santonastaso et al., 1993 [22]
Italy
not reported
F
osteotomy
CT
somnolence, asthenia, hypotension
not reported
11
Ries et al., 1994 [23]
USA
61
F
bilateral total knee arthroplasty
autopsy
abdominal discomfort, nausea, collapse
none
12
Cozzolino et al., 1997 [24]
USA
66
F
total knee arthroplasty
CT
nausea, anorexia, emesis, lethargy
hyponatremia, hyperkalemia, anemia, azotemia
13
Rowland et al., 1999 [25]
Australia
50
M
unspecified
CT
fever, abdominal pain, dizziness, hypotension
hyponatremia
14
Caubet et al., 1999 [26]
France
63
F
tibial osteosynthesis
CT
fever, hypotension, tachypnea
thrombocytopenia, hyponatremia, hyperkalemia, elevated INR
15
Scheffold et al., 2001 [27]
Germany
63
M
intracondylar nail-extension
abdominal ultrasound
abdominal pain, fever
leukocytosis
16
LaBan et al., 2003 [28]
USA
82
F
bilateral knee arthroplasty
CT
abdominal pain, nausea
elevated INR, hyponatremia
17
Schuchmann et al., 2005 [8]
USA
83
F
bilateral total knee arthroplasty
autopsy
anxiety, hypertension, midback pain, shortness of breath, shock
hyponatremia, hypochloremia, leukocytosis, anemia, elevated INR
18
Kurtz and Yang, 2007 [29]
USA
54
F
total hip arthroplasty
CT
fever, abdominal pain, orthostatic syncope
not reported
19
Mongardon et al., 2007 [30]
France
64
M
total hip arthroplasty
CT
fever, abdominal pain, confusion, hypotension
thrombocytopenia, high urinary sodium
20
Thota et al., 2012 [31]
USA
68
M
bilateral total knee arthroplasty
CT
fever, abdominal discomfort, anorexia, fatigue, hypertension, tachycardia, altered mental status
hyperglycemia, leukocytosis, anemia, thrombocytopenia, hyponatremia
21 Chow et al., 2012 [32] USA 44 M bilateral total knee arthroplasty CT hypotension, abdominal pain, tachycardia, fever leukocytosis, D-dimers elevation, hyponatremia, thrombocytopenia

[TableWrap ID: T2] Table 2 

Adrenal insufficiency after any surgery except for orthopaedic surgery


Cases Author Country Age Sex Type of surgery Diagnosis Symptoms Lab results
1
Steer and Fromm, 1980 [33]
USA
71
M
cholecystectomy
not done
abdominal pain, fever, vomiting, anorexia, weakness, hypotension
eosinophilia, hyponatremia, hyperkalemia, prothrombin time elevation
2
Jacobson et al., 1986 [34]
USA
55
M
retropubic prostatectomy
CT
fever, tachycardia, hypotension, dyspnea, abdominal pain, nausea, vomiting, diarrhea, ileus
hyponatremia, hyperkalemia
3
Miller et al., 1986 [35]
USA
81
F
aorto-iliac aneurysmectomy
CT
fever, nausea, vomiting, abdominal pain, lethargy
hyponatremia, hyperkalemia, leukocytosis
4
Homcy and Southern, 1989 [36]
USA
71
M
colectomy
autopsy
confusion, hypotension
hyponatremia
5
Ting et al., 1992 [37]
USA
62
M
coronary bypass grafting
CT
left flank pain, fever, tachypnea, tachycardia, tired, hypotension
leukocytosis, hyponatremia, hyperkalemia
6
Leschi et al., 1994 [38]
France
63
M
aortofemoral bypass graft
autopsy
confusion
hyponatremia, hyperkalemia
7
Belmore and Walters, 1995 [39]
USA
53
M
laparoscopic cholecystectomy
CT
abdominal pain, anorexia, fatigue, hypotension, dehydration
hyponatremia, hyperkalemia, hyperamylasemia, partial thromboplastin time prolonged
8
Scheiwiller et al., 2002 [40]
Switzerland
71
M
low anterior rectum resection
CT
anorexia, abdominal pain, fever, hypotension
hyponatremia
9
Sousa Escandon et al., 2002 [41]
Spain
82
M
partial nephrectomy for renal adenocarcinoma
CT
abdominal pain, nausea, fever, hypotension, severe respiratory distress
hyponatremia, azotemia, anemia, leukocytosis, thrombocytosis
10
Bakaeen et al., 2005 [42]
USA
51
M
coronary artery bypass graft
CT
fever, abdominal pain, diarrhea, orthostatic hypotension, tachycardia
thrombocytopenia
11
Gutenberg et al., 2007 [43]
Germany
69
M
intracranial tumor surgery
exploratory laparotomy
hypotension, abdomen tense
not reported
12
Munoz Corsini et al., 2008 [44]
Spain
63
M
right hemicolectomy
CT
disorientation, difficulty in breathing, tachycardia, fever
leukocytosis, anemia, increase in fibrinogen,
13
Peel and Whitelaw, 2011 [45]
USA
60
M
right hemicolectomy
CT
backache, fever, hypotension, agitation, confusion
hyponatremia, thrombocytopenia, leukocytosis
14
Rosenberger et al., 2011 [2]
USA
69
M
gastrectomy, esophagojejuno- stomy, cholecystectomy
CT
abdominal and flank pain, tachypnea, tachycardia, hypotension, oliguria, myocardial infarction
oliguric renal failure
15 Balsach Sole et al., 2012 [46] Spain 70 M cephalic duodenopancreatectomy CT lethargy, hypotension hyponatremia, hypoglycemia


Article Categories:
  • Case Report

Keywords: Adrenal insufficiency, Arthroplasty, Heparin.

Previous Document:  FeCl3.6H2O, a catalyst for the diastereoselective synthesis of cis-isoxazolidines from N-protected d...
Next Document:  Validity of a computer-assisted manual segmentation software to quantify wrist erosion volume using ...