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To the Editor: In their article “The clinical picture: bilateral adrenal masses” in the December 2012 issue,1 Drs. Saberi and Esfandiari provide excellent points about adrenal hemorrhage as a differential diagnosis for adrenal masses. However, there are two points worth emphasizing when mentioning this diagnosis, especially in the case they presented.
Drs. Saberi and Esfandiari cryptically mention this patient’s coagulopathy (with thrombocytopenia and a rise in creatinine) and anticoagulation as the probable causes of adrenal hemorrhage. We wonder if a diagnosis of antiphospholipid syndrome (APS) was overlooked. Even though overt Addison disease is reported in only 0.4% of patients with APS2 and APS is diagnosed in fewer than 0.5% of all patients with Addison disease,3 we think that in this case, since the patient initially presented with an arterial thrombus in the abdominal aorta, screening for APS would have been warranted.
Second, though it is rare, bilateral adrenal hemorrhage with normal imaging on initial presentation has been described,2,4 which raises this additional question: Should screening for adrenal insufficiency in a patient with possible APS or other coagulopathy be done early while waiting for repeat computed tomography to reveal hemorrhage? Occasionally, intraparenchymal microhemorrhages may not be recognized by sectional imaging but can nonetheless compromise adrenal function.4
- Saberi S, Esfandiari NH. The clinical picture: bilateral adrenal masses. Cleve Clin J Med 2012; 79:841–842.
- Espinosa G, Santos E, Cervera R, et al. Adrenal involvement in the antiphospholipid syndrome: clinical and immunologic characteristics of 86 patients. Medicine (Baltimore) 2003; 82:106–118.
- Presotto F, Fornasini F, Betterle C, Federspil G, Rossato M. Acute adrenal failure as the heralding symptom of primary antiphospholipid syndrome: report of a case and review of the literature. Eur J Endocrinol 2005; 153:507–514.
- Satta MA, Corsello SM, Della Casa S, et al. Adrenal insufficiency as the first clinical manifestation of the primary antiphospholipid antibody syndrome. Clin Endocrinol (Oxf) 2000; 52:123–126.
To the Editor: In their article “The clinical picture: bilateral adrenal masses” in the December 2012 issue,1 Drs. Saberi and Esfandiari provide excellent points about adrenal hemorrhage as a differential diagnosis for adrenal masses. However, there are two points worth emphasizing when mentioning this diagnosis, especially in the case they presented.
Drs. Saberi and Esfandiari cryptically mention this patient’s coagulopathy (with thrombocytopenia and a rise in creatinine) and anticoagulation as the probable causes of adrenal hemorrhage. We wonder if a diagnosis of antiphospholipid syndrome (APS) was overlooked. Even though overt Addison disease is reported in only 0.4% of patients with APS2 and APS is diagnosed in fewer than 0.5% of all patients with Addison disease,3 we think that in this case, since the patient initially presented with an arterial thrombus in the abdominal aorta, screening for APS would have been warranted.
Second, though it is rare, bilateral adrenal hemorrhage with normal imaging on initial presentation has been described,2,4 which raises this additional question: Should screening for adrenal insufficiency in a patient with possible APS or other coagulopathy be done early while waiting for repeat computed tomography to reveal hemorrhage? Occasionally, intraparenchymal microhemorrhages may not be recognized by sectional imaging but can nonetheless compromise adrenal function.4
To the Editor: In their article “The clinical picture: bilateral adrenal masses” in the December 2012 issue,1 Drs. Saberi and Esfandiari provide excellent points about adrenal hemorrhage as a differential diagnosis for adrenal masses. However, there are two points worth emphasizing when mentioning this diagnosis, especially in the case they presented.
Drs. Saberi and Esfandiari cryptically mention this patient’s coagulopathy (with thrombocytopenia and a rise in creatinine) and anticoagulation as the probable causes of adrenal hemorrhage. We wonder if a diagnosis of antiphospholipid syndrome (APS) was overlooked. Even though overt Addison disease is reported in only 0.4% of patients with APS2 and APS is diagnosed in fewer than 0.5% of all patients with Addison disease,3 we think that in this case, since the patient initially presented with an arterial thrombus in the abdominal aorta, screening for APS would have been warranted.
Second, though it is rare, bilateral adrenal hemorrhage with normal imaging on initial presentation has been described,2,4 which raises this additional question: Should screening for adrenal insufficiency in a patient with possible APS or other coagulopathy be done early while waiting for repeat computed tomography to reveal hemorrhage? Occasionally, intraparenchymal microhemorrhages may not be recognized by sectional imaging but can nonetheless compromise adrenal function.4
- Saberi S, Esfandiari NH. The clinical picture: bilateral adrenal masses. Cleve Clin J Med 2012; 79:841–842.
- Espinosa G, Santos E, Cervera R, et al. Adrenal involvement in the antiphospholipid syndrome: clinical and immunologic characteristics of 86 patients. Medicine (Baltimore) 2003; 82:106–118.
- Presotto F, Fornasini F, Betterle C, Federspil G, Rossato M. Acute adrenal failure as the heralding symptom of primary antiphospholipid syndrome: report of a case and review of the literature. Eur J Endocrinol 2005; 153:507–514.
- Satta MA, Corsello SM, Della Casa S, et al. Adrenal insufficiency as the first clinical manifestation of the primary antiphospholipid antibody syndrome. Clin Endocrinol (Oxf) 2000; 52:123–126.
- Saberi S, Esfandiari NH. The clinical picture: bilateral adrenal masses. Cleve Clin J Med 2012; 79:841–842.
- Espinosa G, Santos E, Cervera R, et al. Adrenal involvement in the antiphospholipid syndrome: clinical and immunologic characteristics of 86 patients. Medicine (Baltimore) 2003; 82:106–118.
- Presotto F, Fornasini F, Betterle C, Federspil G, Rossato M. Acute adrenal failure as the heralding symptom of primary antiphospholipid syndrome: report of a case and review of the literature. Eur J Endocrinol 2005; 153:507–514.
- Satta MA, Corsello SM, Della Casa S, et al. Adrenal insufficiency as the first clinical manifestation of the primary antiphospholipid antibody syndrome. Clin Endocrinol (Oxf) 2000; 52:123–126.