THE NEW ZEALAND MEDICAL JOURNAL

Antiphospholipid syndrome (APS) is a disorder in which patients have thrombotic manifestations and/or recurrent spontaneous pregnancy losses, with laboratory evidence of autoantibodies that recognise anionic phospholipid-protein complexes.1 Thrombotic manifestations include venous thromboembolism, cerebrovascular accidents (CVAs), and myocardial infarction. We report a case of adrenal haemorrhage as the presenting manifestation of APS. Case report A 36-year-old male construction worker presented with acute onset of constant mid-abdominal pain, fever, nausea, and vomiting. His mother had three spontaneous pregnancy losses. On exam, he was febrile, tachycardic, and normotensive. Abdominal exam was notable for generalised tenderness. Laboratory studies showed a haematocrit of 32.4%, WBCs of 16,200 /µL with 80 % neutrophils, sodium 138 meq/L, potassium 3.8 meq/L, prothrombin time 11 sec (11-14 sec), activated thromboplastin time 38 sec (26–34 sec), mixing PTT 34 sec with control and 36 sec with patient’s plasma (control = normal saline and pooled plasma; mixing pool = pooled plasma and patient plasma). CT Abdomen with contrast showed a small right pleural effusion and left adrenal haemorrhage (Figure 1). PPD, HIV, and anti-nuclear antibody were negative. Anti-cardiolipin IgA, IgM, and IgG, anti β2-glycoprotein-1 IgA, IgM, and IgG were elevated. Lupus anticoagulant was positive as determined by the dilute Russell Viper Venom Time (DRVVT) test. Figure 1. Non-contrast axial CT scan demonstrating acute left adrenal haemorrhage (arrow