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Adrenal haemorrhage and pseudoaneurysm: case report A 67-year-old man developed adrenal haemorrhage and pseudoaneurysm following anticoagulation therapy with aspirin, rivaroxaban and ticagrelor [routes not stated, not all dosages stated]. The morbidly obese man initially presented with non-specific right-sided abdominal pain and right-sided chest pain. He had been receiving rivaroxaban for atrial fibrillation. Prior to the presentation, he was treated as per non-ST segment elevated myocardial infarction, and subsequently, he received loading doses of ticagrelor 180mg and aspirin 300mg. After examination, it was thought that his chest pain was due to lower respiratory tract infection; hence, ticagrelor was stopped. Five days later (at current presentation), he was hospitalised due to constant right lower quadrant abdominal pain, along with irregular radiation to the lower back. Anamnesis revealed that, he had localised perforation of sigmoid diverticulitis 12 months previously, which was managed non-operatively. On presentation, he was found to be haemodynamically stable and afebrile. His vital signs were as follows: body temperature 36.4°C, pulse 83 beats/min, BP 152/83mm Hg and RR 16 /min. Upon examination, localised tenderness on the right lower abdomen without guarding was observed. Laboratory tests revealed the following: haemoglobin 142 g/L, white cell count 15 x 1012/L, platelet 192 /L, creatinine 90 µmol/L and C-reactive protein 150.1 mg/L, while coagulation profile showed abnormal results. A CT scan of the pelvis and abdomen showed the right adrenal mass connected with peri-right adrenal and adrenal stranding, suggestive of adrenal haemorrhage. A triphasic CT scan showed the right adrenal haematoma. Hence, the man was transferred to the tertiary hospital. Before the transfer, he was treated with prothrombinex and vitamin K for reversal of coagulopathy. Two days later, the repeat CT scan showed pseudoaneurysm at the right adrenal artery, which remained unchanged in size. Also, his fasting plasma metanephrines were normal. Therefore, the radiologist tried angio-embolisation of the pseudoaneurysm, which was unsuccessful due to the spasm and tortuosity of the right adrenal artery. Hence, he was treated conservatively, and on day 5 of hospitalisation, he was discharged after clinical improvement. One month later, a repeat CT scan showed the stable appearance of the pseudoaneurysm, and six months later, imaging showed a significant decrease in the size of the right adrenal pseudoaneurysm. Seow YT, et al. Anticoagulation-induced unilateral adrenal haemorrhage and pseudoaneurysm. BMJ Case Reports 12: No. 12, Dec 2019. Available from: URL: http:// 803448226 doi.org/10.1136/bcr-2019-232539

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Reactions 25 Jan 2020 No. 1788