Abstract
Introduction: Bilateral adrenal hemorrhage (BAH) is seldomly recognized as a cause of adrenal insufficiency due to nonspecific clinical manifestations within the milieu of major concurrent illnesses. CT abdomen is the investigation of choice to evaluate acute adrenal crisis.
Clinical Case: A 68 year old female with systemic lupus erythematosus, anti-phospholipid antibody syndrome (APS) complicated by multiple strokes, on warfarin, and recent hip fracture presented with confusion, lethargy, fever, and cough. On exam she was febrile, tachycardic, tachypneic, disoriented with right sided hemiparesis, and crepitations on lung auscultation. Lab results were significant for leukocytosis of 14K/uL, hemoglobin (Hb) 9.9g/dL, INR 3.8, azotemia, normal electrolytes, and glucose 67mg/dL. Blood and urine cultures were negative. Anti-dsDNA, C3, and C4 were normal. CT chest showed right lower lobe infiltrates and bronchial debris. She was treated with antibiotics and bronchoscopy with mucus plug removal. Her lethargy and confusion persisted. MRI brain was negative for acute event. Hb fell to 7g/dL; managed conservatively with i.v. iron. CT abdomen showed BAH both measuring 3.5x3.5cm; AM cortisol was 5.5 mcg/dL. Warfarin was reversed with vitamin K; hydrocortisone 50mg q8h was started with improvement in her mental status. ACTH levels were <5pg/ml; ACTH stimulation testing was deferred as steroids were started emergently. Repeat CT showed stable BAH, AM cortisol increased to 19.4mcg/dL, and Hb stable at 8g/dL. She was discharged on hydrocortisone 10mg twice daily.
Discussion: Trauma, corticotropin stimulation during stress, anticoagulation therapy, and APS inducing adrenal venous thrombosis have been identified as risk factors that predispose to BAH. There is a lack of consensus regarding normal cortisol levels in critical illness. Fluctuations in serum cortisol levels are frequent and not necessarily indicative of definite injury to the adrenal gland. CT abdomen, the investigation of choice in the acute setting, has a heterogeneous, high density appearance; the presence of an underlying adrenal mass cannot be excluded. BAH appears as diminished attenuation of the adrenal gland with respect to the adjacent tissues, along with thickening of the ipsilateral crura due to retroperitoneal extension of blood (1). MRI has a greater accuracy for identifying BAH in comparison to CT as it can discern adrenal hematoma from adjacent necrotic tissue and determine the acuity of the hematoma.
Conclusion: The nonspecific clinical manifestations of BAH are frequently inseparable from those of the concurrent major illness. The diagnosis requires a high index of suspicion, initiation of prompt steroid replacement, and confirmation by CT abdomen.
References: (1) Fatima, Z., Tariq, U., Khan, A., et. Al. A Rare Case of Bilateral Adrenal Hemorrhage. Cureus. 2018 Jun; 10(6): e2830. doi: 10.7759/cureus.2830
Spontaneous bilateral adrenal hemorrhage of pregnancy