Page 22 - Delaware Medical Journal-October
P. 22
Delayed Unilateral Adrenal Hemorrhage Complicating Pneumococcal Septic Shock Jeff Wharton, MD; David Cohen, MD
An 80-year-old male presented to the hospital after being found unresponsive at home. He was found to have pneumococcal pneumonia complicated by septic shock. He was treated in the medical ICU briefly with vasopressors and received intravenous antibiotics. He achieved a full recovery and was discharged after 10 days. He returned
within 24 hours with vague abdominal and chest pain. His complaints of pain were difficult to localize — radiating
from back to chest and abdomen. He received an extensive work-up to exclude acute coronary syndrome, pulmonary embolism, pancreatitis, cholecystitis, and rib fracture. He was ultimately found to have a symptomatic unilateral adrenal hemorrhage, likely secondary to the acute stress of septic shock.
CASE REPORT
hypertension, hyperlipidemia, and chronic obstructive pulmonary disease was found down and unresponsive by a family member after a six-day history of productive cough and pleuritic chest pain. He was brought to the emergency department and was found to be minimally responsive, hypothermic, and tachycardic. Laboratory work-up revealed a leukocytosis of 28,000, acute kidney injury with a creatinine of 2.6 mg/dL, hemoglobin of 12.6 g/dL and an the chest showed a consolidation in the right middle and lower lobes and streptococcus urinary antigen was positive. The patient had worsening hypotension and required admission to the medical with azithromycin and ceftriaxone and required less than 24 hours of norepinephrine for maintenance of blood pressure. The patient’s clinical status improved and his laboratory results normalized over the following week. He completed a course of azithromycin and ceftriaxone in the hospital and was discharged after 10 days.
The patient was re-admitted to the hospital within 24 hours of discharge with acute onset, moderate intensity, sharp, right- sided sub-sternal chest and epigastric pain. The pain was not associated with food intake, nausea, vomiting, or diarrhea. He was afebrile. He was admitted and received an initial work-up including electrocardiogram, complete blood cell count with with contrast, which were all within normal limits. The patient was admitted and continued to complain of right upper quadrant (RUQ) pain and tenderness to palpation as well as right-sided
pleuritic chest pain. He received an ultrasound of the abdomen on re-admission day 2, which revealed cholelithiasis without ductal dilatation or sonographic Murphy’s sign. On re-admission
for pulmonary embolus, and an x-ray of the ribs negative for fracture. On this day he also received an MRI of the abdomen, revealing a 31 x 25mm right adrenal gland hemorrhage, not (Figure 1). Surgery was consulted and recommended non-operative management. A morning cortisol was checked and was within normal limits, and his blood pressure and vital signs remained within the normal range. His pain regimen was advanced and he was discharged to a skilled nursing facility.
DISCUSSION
Epidemiology
Adrenal Hemorrhage (AH) is a rare, but serious condition with reported incidence in unselected autopsy studies ranging from 0.14 to 1.8 percent.1 The incidence of AH may be much greater in critically ill patients. An analysis of autopsies in patients who died from shock found a much higher rate of AH of 15.4 percent.2 AH may be unilateral or bilateral, with focal or diffuse hemorrhagic foci. A 25-year retrospective analysis of AH has been previously subtypes; including stress- or sepsis-mediated (40 percent), (APS) or heparin induced thrombocytopenia (HIT) -associated (14 percent), spontaneous symptomatic presentation (11 percent), post-operative (10 percent), trauma-related (3 percent) or related to anticoagulants (2 percent).3 Other precipitating conditions include pregnancy, pancreatitis, primary or metastatic carcinoma,
310
Del Med J | October 2015 | Vol. 87 | No. 10
Abstract
