Ischemic Colitis and Adrenal Insufficiency: Unusual Manifestations of the Antiphospholipid Antibody Syndrome

1Staten Island University Hospital, Staten Island, NY
2Staten Island University Hospital, Staten Island, NY
3Staten Island University Hospital, Staten Island, NY

Meeting: Hospital Medicine 2009, May 14-17, Chicago, Ill.

Abstract number: 138

Case Presentation:

A 56‐year‐old man presented with 2 days of severe diffuse abdominal pain and diarrhea. CT scan of the abdomen and pelvis revealed diffuse colitis in the transverse, descending, and sigmoid colon. Admission labs were WBC 28.6, Hgb 13.9, HCT 41.0, platelets 129 K, and PTT > 120 seconds. Stool cultures, Clostridium difficile toxin, and disseminated intravascular coagulation panel were negative. During the hospital course, the patient underwent a colonoscopy, which revealed necrotic tissue with fibri‐nopurulent exudates consistent with ischemic colitis. A hypercoagulable workup revealed anticardiolipin, antiphospholipid, and B2 gly‐coprotein antibodies consistent with antiphospholipid antibody syndrome (APS). Despite the diagnosis, the patient refused warfarin and continued to remain only on subcutaneous heparin for deep vein thrombosis prophylaxis. On hospital day 17, he developed a drop in his hemoglobin, from 8.1 to 6.9. Repeat CT of the abdomen and pelvis revealed left adrenal gland enlargement with probable hemorrhage. Despite red blood cell transfusions, he complained of dizziness, weakness, and decreased appetite. His labs were significant for Na 128 meq/L and K 5.32 meq/L, and vital signs revealed orthostatic hypotension. A cosyntropin stimulation test showed an initial serum cortisol of 1.52 μg/dL, which increased to only 1.83 μg/dL after 30 minutes, consistent with adrenal insufficiency. He was started on steroids with relief of his symptoms.

Discussion:

APS typically presents with thromboembolic venous or arterial disease including deep vein thrombosis/pulmonary embolism, recurrent fetal loss, and thrombocytopenia. Ischemic colitis has been reported in approximately 4% of APS patients, whereas adrenal insufficiency presents in only 0.4%. Intestinal manifestations typically include thrombosis of the large veins. Small vessel ischemia as seen in our patient is rare. Given its association with a hypercoagulable state, treatment with anticoagulation is recommended. Adrenal hemorrhage is a relatively uncommon condition that may lead to acute adrenal crisis, shock, and death unless recognized promptly. In patients with APS, it is thought be to secondary to adrenal vein thrombosis, resulting in parenchymal bleeding. Usually approximately 90% of the adrenal gland needs to be affected before adrenal insufficiency occurs. Left adrenal gland involvement alone would not account for the amount of adrenal insufficiency seen in our patient. It is hypothesized that the right adrenal grand may have been affected with previous episodes of hemorrhage. Patients with adrenal insufficiency require steroid replacement and may also require mineralocorticoid replacement secondary to hypoaldosteronism.

Conclusions:

To facilitate accurate diagnosis and prompt treatment, hospitalists should be aware of the rare but important association of APS with ischemic colitis and adrenal insufficiency.

Author Disclosure:

T. Abdallah, none.

To cite this abstract:

Abdallah T, Patel M, Gottesman A. Ischemic Colitis and Adrenal Insufficiency: Unusual Manifestations of the Antiphospholipid Antibody Syndrome. Abstract published at Hospital Medicine 2009, May 14-17, Chicago, Ill. Abstract 138. Journal of Hospital Medicine. 2009; 4 (suppl 1). https://www.shmabstracts.com/abstract/ischemic-colitis-and-adrenal-insufficiency-unusual-manifestations-of-the-antiphospholipid-antibody-syndrome/. Accessed July 16, 2019.

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