A 26-years-old African primigravida patient was evaluated at our department at 30 + 2 weeks of gestation with abdominal pain and a reduction of uterine cervical length in a suspected preterm labor. During the observation, she developed a sudden onset of upper quadrant acute severe abdominal pain, which radiated posteriorly, complaining of nausea, emesis, and an increased state of agitation. In addition, severe hypotension was refractory to hydration. In order to exclude abrutio placentae or uterine rupture, we performed a cardiotocography and fetal ultrasound without detecting any abnormalities. The features of pain and the clinical findings could be associated with intestinal volvulus with vascular ischemia or acute pancreatitis. Blood exams showed an increase of inflammatory markers (WBC 31 x 103/ml). Hemoglobin and pancreatic enzymes were in the normal range and urinalysis revealed no signs of blood loss or infection. For the worsening of pain, which was non-responsive to analgesics (paracetamol and opiates), she was scheduled for enhanced computed tomography (CT). It showed an imbibition of the adrenal lodges identifying ill-defined glands. The mean density was about 50 UH (Figure 1). With a hypothesis of adrenal disease, a magnetic resonance imaging (MRI) was performed and it confirmed the suspicion of hyperacute bilateral adrenal hemorrhagic infarction, associated with minimal left anterior pararenal blood fluid film without focal lesions (Figures 2, 3). The patient did not previously intake aspirin or heparin. ACTH was higher than normal (109 pg/ml) and Cortisol below the normal range (10.4 mcg/dL). Urinary metanephrines and normetanephrines were 5 times over the normal range (1461.2 mcg/24 h and 1,352 mcg/24 h, respectively), and urinary catecholamines demonstrated Dopamine 452.4 mcg/24 h, Adrenaline 123.7 mcg/24 h, and Noradrenaline 455 mcg/24 h. Electrolytes values revealed Hyponatremia, Hypomagnesemia, Hypocalcemia, and Hypokalemia: Na + 134.8 mEq/L; K + 3.14 mEq/L; Cl- 104 mEq/L; Ca + + 8.3 mg/dL, Mg + + 1.5 mg/dL. Hyperglycemia was reported: 185 mg/dL. The patient was transferred to the intensive care unit to permit intensive monitoring of her condition with suspected adrenal hemorrhage. During this period, fetal monitoring was performed to prevent fetal heart failure resulting from maternal hypotension. The treatment included intravenous saline infusion (2 l of 0.9% saline and intravenous hydrocortisone with a dosage of continuous infusion of 200 mg in 24 h).
After 3 days, the patient returned to the obstetric unit, and cortisone acetate was administered at a dose of 25 mg 1 + 1/2 tablet daily and antibiotic therapy was started upon the resolution of symptoms: Cortisol 6.9 mcg/dL, ACTH 38 pg/ml, normal plasmatic electrolytes, urinary normetanephrines 387 mcg/24 h, and metanephrines 866.6 h. Due to the nationality of the patient we decided to test for fecal and urine Koch's Bacillus, which gave a positive result. The tuberculin skin test and the QuantiFERON test resulted positive. In addition, the patient tested positive for urinary cocaine metabolites because she had a previous history of drug addiction. The treatment in the hospital at the time of discharge after 4 weeks of hospitalization consisted of: cortisone acetate 25 1 + 1/2 tablet daily, rifampicin, ethambutol, and isoniazid. This therapy schedule was also continued after hospital discharge. The patient returned for a second MRI after 4 Weeks (Figure 4). The adrenal glands showed regular morphology and size, with substantially homogeneous intensity of signal.
The patient delivered a newborn weighing 2,795 g at term (40 weeks) Intravenous hydrocortisone was administered 100 mg iv during labor and followed by continuous infusion of hydrocortisone (200 mg in 24 h). No complications were seen during delivery. Post-partum was physiological with good therapeutic compliance. No medical issues have been identified in the child. Placental histology showed a massive macrophagous infarction of the membranes. No evidence of mycobacterium tuberculosis was retrieved in the specimens. The patient underwent regular follow-up which reported no secondary tuberculosis and showed good management of infection. The patient continued the endocrinological follow-up in another center.