Acute adrenal insufficiency secondary to heparin-induced thrombocytopenia-thrombosis syndrome

Abstract

Objective: To present a case of acute adrenal insufficiency secondary to heparin-induced thrombocytopenia-thrombosis syndrome (HITTS), an important though rare complication of heparin therapy.

Clinical features: A 69-year-old woman developed HITTS secondary to low dose heparin administered subcutaneously as prophylaxis against deep venous thrombosis. This followed a revision of a knee replacement. The first manifestation of HITTS was the development of pulmonary emboli in the setting of a falling platelet count. Bilateral adrenal haemorrhages complicated her course resulting in acute adrenal insufficiency. Non-specific symptoms dominated the clinical picture, with fever, nausea, abdominal pain and vomiting. Symptomatic postural hypotension was noted later in the course of her illness.

Intervention and outcome: The diagnosis of adrenal insufficiency was confirmed by short Synacthen test plus computed tomographic scanning which demonstrated bilateral adrenal haemorrhages. Steroid replacement resulted in rapid clinical improvement.

Conclusions: This case demonstrates one of the life threatening complications that may occur with heparin even in prophylactic doses. Regular platelet counts are essential to detect heparin-induced thrombocytopenia at an early stage.