Bilateral Cerebral Strokes and Adrenal Hemorrhage Associated with Mis-A

INTRODUCTION: Multisystem Inflammatory Syndrome in Adults (MIS-A) is an underrecognized post-infectious manifestation of COVID-19.We report a case of a 21-year-old male with MIS-A who presented with adrenal hemorrhages, acute kidney injury (AKI) and cerebral strokes leading to multiorgan system failure and death. DESCRIPTION: A 21-year-old, morbidly obese male presented at an outside hospital with COVID-19 and abdominal pain. His abdominal CT demonstrated bilateral adrenal hemorrhages, he was discharged home on hydrocortisone. A month later was readmitted with fever, diarrhea, thrombocytopenia and AKI. Laboratory work revealed creatinine 5.49mg/dL, ferritin 701ng/ml, BNP 3020 pg/ml and D-Dimer 17,650 ng/ml. He received hydrocortisone, intravenous immunoglobulin and enoxaparin. Fever subsided and renal function normalized. On day 7 he developed acute altered mental status and recurrent AKI. Head CTA showed multiple short stenotic segments in the anterior circulation, diminutive appearance of several intracranial arteries and basal ganglia hypodensities. Brain MRA demonstrated extensive bilateral acute/subacute strokes, no evidence of sinus thrombosis and markedly decreased caliber of internal carotid, left middle and anterior cerebral arteries without evidence of thrombus. He received aggressive neurocritical care management including decompressive craniectomy and pulse steroids for suspected vasculitis. Due to the severity of his neurological injury and poor neurologic prognosis family elected to withdraw support. His autopsy demonstrated hepatomegaly, acute tubular necrosis, bilateral adrenal hemorrhages and hypercellular bone marrow with myeloid predominance. Neuropathology showed severe segmental stenosis of the carotid arteries and bilateral vertebral arteries. DISCUSSION: Stroke is a potentially life-threatening complication of COVID-19 including large vessel occlusion and less frequently vasculitis-like phenotype with vessel wall enhancement. Despite initial improvement, our patient developed an acute extensive ischemic stroke leading to a devastating neurologic injury. The neuropathology findings suggest SARS-CoV-2 associated vasculitis. Stroke in the context of COVID-19 may have different pathogenetic mechanisms, clinical characteristics and complications that warrant further investigation.

IMPORTANCE OF STEROIDS: A CASE OF SPONTANEOUS BILATERAL ADRENAL HEMORRHAGE DUE TO THROMBOCYTOPENIA IN A PATIENT WITH MYELODYSPLASTIC SYNDROME

SESSION TITLE: Emergency Endocrine Disorders SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Spontaneous bilateral adrenal hemorrhage (BAH) resulting in adrenal crisis is a rare, but serious condition that can easily be missed as patients may present with non-specific symptoms (weakness, fatigue, nausea, vomiting, dizziness). It can escalate to hemodynamic instability in the setting of adrenal crisis. The most common cause is meningococcal disease, other causes include trauma, septicemia, and coagulopathies. Without treatment it is fatal and carries a high mortality rate of 15%;Waterhouse-Friderichsen syndrome has been reported with 55-60% mortality. Here, we describe a case of a patient with a history of myelodysplastic syndrome (MDS) who presented with multiple readmissions with a septic shock picture with unknown source of infection and was finally diagnosed with bilateral adrenal hemorrhage causing adrenal crisis. CASE PRESENTATION: An 85-year old independently living man with past medical history of MDS and hypertension presented after a syncopal episode at home with altered mental status. Treatment was initiated for a urinary tract infection which progressed to shock. His labs were notable for leukocytosis in the 40,000s and a platelet count in the 30s. He was found to have BAH on imaging. He was started on broad-spectrum antibiotics, vasopressors and stress-dose steroids with improvement in his condition and eventually discharged home. He was readmitted to the ICU twice within a month for shock, each time with a negative infection workup, as he had been discharged home without steroids to follow up with an endocrinologist. After his third readmission, he was discharged on steroids and he did not have any further readmissions to the hospital. Exhaustive investigations were made into possible infectious causes of his BAH as well as possible vasculitis and hematologic causes. It was determined to likely be in the setting of thrombocytopenia brought on by his MDS. DISCUSSION: Thrombocytopenia is a rare cause of BAH and adrenal crisis. Review of literature mostly describes cases of heparin-induced thrombocytopenia, a few cases of COVID19 and vaccine-induced immune thrombocytopenia after the COVID vaccine. In our patient, it was thought that MDS predisposed him to spontaneous BAH and subsequently adrenal crisis, which has only been described once before in the literature. Stress dose steroids are commonly used in the ICU for relative adrenal insufficiency. Due to the acuity of his condition and concern for relative adrenal insufficiency, our patient was tapered off steroids and discharged home with endocrinology follow up which led to his frequent readmissions as his underlying problem was not addressed. CONCLUSIONS: Adrenal insufficiency is rare and may be difficult to diagnose especially in the acute setting. It is important to recognize and treat adrenal crisis as it has a high mortality rate. MDS is a rare cause. Reference #1: Manganaro L, Al Ansari N, Barchetti F, et al. Bilateral Adrenal Hemorrhage in a Patient with Myelodysplastic Syndrome: Value of MRI in the Differential Diagnosis. Case Reports in Radiology. 2013;2013:e479836. doi:10.1155/2013/479836 Reference #2: 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 thrombocytopenia. Crit Care Med. 2011;39(4):833-838. doi:10.1097/CCM.0b013e318206d0eb Reference #3: Fatima Z, Tariq U, Khan A, et al. A Rare Case of Bilateral Adrenal Hemorrhage. Cureus. 2018;10(6):e2830. Published 2018 Jun 18. doi:10.7759/cureus.2830 DISCLOSURES: No relevant relationships by Robbert Crusio No relevant relationships by Justyna Michalik No relevant relationships by Aditya Saholi

Bilateral adrenal hemorrhage in a man with severe COVID-19 pneumonia.

This case report demonstrates bilateral adrenal hemorrhage in a fifty-year old man with severe COVID-19 pneumonia. We discuss how adrenal hemorrhage can be one of the possible complications of COVID-19. The case also shows how adrenal hemorrhage can be diagnosed incidentally in a scan performed for a different reason given the difficulty of clinical diagnosis and the non-specific clinical presentation.

Bilateral Adrenal Hemorrhage in Coronavirus Disease 2019 Patient: A Case Report.

CONTEXT: Bilateral adrenal hemorrhage is a rare condition with potentially life-threatening consequences such as acute adrenal insufficiency. Early adrenal axis testing, as well as directed imaging, is crucial for immediate diagnosis and treatment. Coronavirus disease 2019 (COVID-19) has been associated with coagulopathy and thromboembolic events. CASE DESCRIPTION: A 66-year-old woman presented with acute COVID-19 infection and primary adrenal insufficiency due to bilateral adrenal hemorrhage (BAH). She also had a renal vein thrombosis. Her past medical history revealed primary antiphospholipid syndrome (APLS). Four weeks after discharge she had no signs of COVID-19 infection and her polymerase chain reaction test for COVID-19 was negative, but she still needed glucocorticoid and mineralocorticoid replacement therapy. The combination of APLS and COVID-19 was probably responsible of the adrenal event as a "two-hit" mechanism. CONCLUSIONS: COVID-19 infection is associated with coagulopathy and thromboembolic events, including BAH. Adrenal insufficiency is life threatening; therefore, we suggest that early adrenal axis testing for COVID-19 patients with clinical suspicion of adrenal insufficiency should be carried out.