A 65-Year-Old Man with Bilateral Adrenal Hemorrhage Following Prophylaxis for Postoperative Deep Vein Thrombosis with Rivaroxaban

Abstract

BACKGROUND Direct oral anticoagulant (DOAC) agents, such as rivaroxaban, treat and prevent venous thrombosis. Although adrenal hemorrhage due to DOACs has previously been reported, this is a rare condition that can present as an emergency. In this case report, we present a 65-year-old man who recently had bilateral knee arthroplasty and was started on rivaroxaban 10 mg daily for deep vein thrombosis (DVT) prophylaxis following the surgery. CASE REPORT Ten days after bilateral knee arthroplasty and starting rivaroxaban, the patient presented to the Emergency Department with severe, sudden abdominal pain. Abdominal computed tomography detected significantly enlarged bilateral adrenals, with ill-defined heterogeneous density extending to the upper part of perinephric and paranephric spaces, suggesting bilateral adrenal hemorrhage. A cosyntropin stimulation test was used to confirm the suspicion of adrenal insufficiency. Cortisol levels were 66 nmol/L before stimulation and 83 nmol/L 60 min after cosyntropin administration. Hydrocortisone was started intravenously at a dose of 50 mg every 8 h. After his symptoms improved, he was discharged on oral hydrocortisone at 10 mg in the morning and 5 mg in the evening. Seven weeks after discharge, follow-up abdominal ultrasonography showed that the bilateral adrenal hemorrhage had resolved. CONCLUSIONS This case supports previous cases of adrenal hemorrhage as a rare but serious association with rivaroxaban and highlights the importance of rapid diagnosis using imaging and monitoring of patients for this possible adverse effect. Practitioners must remain vigilant when prescribing anticoagulation therapy, especially in patients who are at an increased risk for adrenal hemorrhage.

Figure 1.

Bilateral adrenal hemorrhage on computed tomography (CT) scan. CT scan on admission showing bilateral significant adrenal glands enlargement, mildly heterogeneous, as denoted by the arrows, with noticeable fat stranding seen extending around the kidneys, diagnostic for adrenal hemorrhage. (A) Transverse view; (B) coronal view.

Figure 2.

Seven-week follow-up ultrasound. Ultrasound showing the reduced size of the right adrenal enlargement, as denoted by the arrow, 3×1.7 cm (previously 4.1×2 cm).