(8.01) Bilateral Adrenal Hemorrhage Causing Acute Adrenal Insufficiency

Adrenal hemorrhage is an under-recognized condition often found incidentally on imaging in acutely ill patients. Unilateral adrenal hemorrhage is usually clinically silent however bilateral adrenal hemorrhage can cause acute primary adrenal insufficiency which can be life threatening. This is a case of acute adrenal insufficiency secondary to bilateral adrenal hemorrhage. 

Case(s) Description :

A 79 year old male with a history of chronic obstructive pulmonary disease presented to the emergency department with a chief complaint of altered mental status.  He initially presented to an outside hospital one day prior with abdominal pain and computed tomography (CT) with contrast demonstrated no discrete adrenal nodules. On repeat imaging, CT abdomen/pelvis without contrast demonstrated new bilateral adrenal masses concerning for bilateral adrenal hemorrhage and possible enteritis. He was started on antibiotics for presumed infection of abdominal source and was transferred to our facility for higher level of care. Repeat CT abdomen and pelvis with and without contrast two days later demonstrated bilateral adrenal masses, 2.9 cm on the left and 3.8 cm on the right, with heterogeneous attenuation consistent with bilateral adrenal hemorrhage which was stable from prior but new from the initial imaging study. Three days after admission he was transferred to the medical intensive care unit due to hypotension requiring pressors. Morning cortisol was 6.6 ug/dL. He was started on hydrocortisone 100 mg every 8 hours and fludrocortisone 0.05 mg daily with improvement in blood pressure. Blood cultures were negative and antibiotics were discontinued. He was discharged home on oral hydrocortisone and fludrocortisone with plans for further workup outpatient. Sick day rules were provided. 

Discussion :

This case illustrates a presentation of acute adrenal insufficiency due to bilateral adrenal hemorrhage. Most signs and symptoms are nonspecific but the most commonly reported are hypotension, mental status changes, and nausea and vomiting which can all be attributed to adrenal insufficiency. Abdominal pain can also occur. On non-contrast cross sectional CT imaging, acute adrenal hemorrhage is seen by the development of high or mixed attenuated adrenal lesion within hours or days, as seen in this patient. Predisposing factors for adrenal hemorrhage that should be considered are adrenal tumors, sepsis, coagulopathies, surgeries, or trauma. Further work up will need to be done to try to determine the etiology of the adrenal hemorrhage as it can be the initial presentation of underlying hematologic disorder or adrenal lesion.