Shock during heparin-induced thrombocytopenia: Look for adrenal insufficiency!

Autor: Nicolas Mongardon, Matthieu Henry-Lagarrigue, Stéphane Legriel, Pierre Guezennec, Laure Revault D’Allonnes, Jean-Pierre Bedos, Fabrice Bruneel, Gilles Troché
Rok vydání: 2006
Předmět:
Zdroj: Intensive Care Medicine. 33:547-548
ISSN: 1432-1238
0342-4642
DOI: 10.1007/s00134-006-0487-9
Popis: Sir, Heparin-induced thrombocytopenia (HIT) can lead to life-threatening complications. We report a case of shock of unclear origin in a patient, in whom investigations showed adrenal insufficiency induced by adrenal necrosis in the setting of HIT. A 64-year-old man received prophylactic subcutaneous unfractionated heparin therapy after hip replacement. On postoperative day (POD) 7, his platelet count was 76,000/mm3 compared with 339,000/mm3 preoperatively, suggesting HIT. Danaparoid was substituted for heparin, and HIT antibodies were tested. On POD 9, he required ICU admission for cardiovascular collapse, fever, confusion, and abdominal pain. Thrombocytopenia (46,000/mm3) and high urinary sodium were the only abnormal laboratory findings. Abdominal computed tomography showed bilateral adrenal gland enlargement (Fig. 1) consistent with hemorrhagic necrosis. Acute adrenal insufficiency caused by HIT-related thrombosis was suspected. Samples for hormone assays were collected and intravenous hydrocortisone was started immediately. The fever, shock, and norepinephrine requirement resolved within 24 h. The ELISA for HIT antibodies came back strongly positive. Basal plasma cortisol was very low (46 nmol/l) and no rise was noted 60 min after corticotropin stimulation test (42 nmol/l). The patient was discharged to a medicine ward on POD 14 with oral hydrocortisone and fludrocortisone. He recovered uneventfully. Heparin-induced thrombocytopenia occurs in 0.5–5% of patients given heparin, depending on patient characteristics and heparin type [1]. The diagnosis is difficult in ICU patients, who often have thrombocytopenia due to other causes (e. g., sepsis, disseminated intravascular coagulation, bleeding, dilution, and drugs other than heparin), in variable combinations. Similarly, the symptoms of acute adrenal insufficiency are nonspecific and may suggest septic shock in ICU patients. Non-specific yet suggestive features include extravascular fluid loss, unresponsiveness to vasoconstrictors, normolactemia, eosinophilia, hyperkalemia, hyponatremia, hypernatriuresis, and relative hypoglycemia [2]. Recent management of septic shock with systematic adrenal function testing may detect early previously unrecognized cases of adrenal failure [3].
Databáze: OpenAIRE
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