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.