title: Acute adrenal insufficiency secondary to heparin-induced thrombocytopenia-thrombosis syndrome.
abstract: OBJECTIVE
  To present a case of acute adrenal insufficiency secondary to heparin-induced thrombocytopenia-thrombosis syndrome (HITTS), an important though rare complication of heparin therapy.
  
  
  METHODS
  A 69-year-old woman developed HITTS secondary to low dose heparin administered subcutaneously as prophylaxis against deep venous thrombosis. This followed a revision of a knee replacement. The first manifestation of HITTS was the development of pulmonary emboli in the setting of a falling platelet count. Bilateral adrenal haemorrhages complicated her course resulting in acute adrenal insufficiency. Non-specific symptoms dominated the clinical picture, with fever, nausea, abdominal pain and vomiting. Symptomatic postural hypotension was noted later in the course of her illness.
  
  
  RESULTS
  The diagnosis of adrenal insufficiency was confirmed by short Synacthen test plus computed tomographic scanning which demonstrated bilateral adrenal haemorrhages. Steroid replacement resulted in rapid clinical improvement.
  
  
  CONCLUSIONS
  This case demonstrates one of the life threatening complications that may occur with heparin even in prophylactic doses. Regular platelet counts are essential to detect heparin-induced thrombocytopenia at an early stage.
authors.affiliation: Rheumatology Department, Rachel Forster Hospital, Redfern, NSW.
authors.forename: J F
authors.initials: JF
authors.lastname: Bleasel
authors.forename: J E
authors.initials: JE
authors.lastname: Rasko
authors.forename: K A
authors.initials: KA
authors.lastname: Rickard
authors.forename: G
authors.initials: G
authors.lastname: Richards
mesh_terms: D000208:Acute Disease; D000309:Adrenal Insufficiency / Q000209:etiology*; D000368:Aged; D005260:Female; D006493:Heparin / Q000009:adverse effects*; D006801:Humans; D007279:Injections, Subcutaneous; D007720:Knee Prosthesis; D012086:Reoperation; D013921:Thrombocytopenia / Q000139:chemically induced* / Q000150:complications*; D013927:Thrombosis / Q000139:chemically induced* / Q000150:complications*
chemical_list: D006493:Heparin