Adrenal hemorrhage: a 25-year experience at the Mayo Clinic

Incidence, Presentation, and Natural History of Adrenal Hemorrhage: An Institutional Analysis

INTRODUCTION

Adrenal hemorrhage (AH) can occur due to multiple etiologies with variable radiographic appearance, often indistinguishable from underlying adrenal neoplasms. There is a lack of AH literature and evidence-based guidelines. Our study aimed to understand the prevalence and etiology of AH, follow-up, and incidence of underlying neoplasm.

METHODS

An institutional database was queried from January 2006 to October 2021 for patients with AH on imaging, excluding patients with known malignancies, adrenal masses, or prior adrenal surgery. Demographics, medical history, hematoma size, laterality, biochemical evaluation, intervention, and additional imaging were reviewed.

RESULTS

Of 490,301 imaging reports queried, 530 (0.11%) with AH met inclusion criteria. Most imaging (n = 485, 91.5%) was performed during trauma evaluation. Two patients underwent dedicated intervention at presentation. Interval imaging was performed in 114 (21.5%) patients at a median of 2.6 (interquartile range 0.99-13.4) mo, with resolution (n = 84, 73.7%) or decreased size of AH (n = 21, 18.4%) in most patients. Only 10 patients (1.9%) saw an outpatient provider in our system to address AH or evaluate for underlying mass, and 9 (1.7%) underwent biochemical screening. Thirteen patients (11% of 118 patients with any follow-up) had evidence of an adrenal mass, confirmed on serial imaging (n = 10) or adrenalectomy (n = 3). Scans performed for nontrauma indications were significantly more likely to have an underlying mass (n = 6/26 [23.1%]) than those performed for trauma evaluation (n = 7/92 [7.6%], P = 0.04).

CONCLUSIONS

AH is a rare finding associated with an increased rate of underlying adrenal mass, particularly when unrelated to trauma. Most AH resolves spontaneously without intervention. Follow-up imaging at 6 mo can help distinguish mass-associated AH from simple hemorrhage.

Adrenal Hemorrhage: A Comprehensive Analysis of a Heterogeneous Entity-Etiology, Presentation, Management, and Outcomes

OBJECTIVE

To investigate the etiology, presentation, management, and outcomes of patients with adrenal hemorrhage (AH).

PATIENTS AND METHODS

Longitudinal study of consecutive adult patients with radiologically confirmed AH (January 1, 2017, through December 31, 2021).

RESULTS

Of the 363 patients with AH (median age, 62 years [interquartile range (IQR, 52-70 years]; 128 women [35%]), 338 (93%) had unilateral AH and 25 (7%) had bilateral AH. It was discovered incidentally in 152 patients (42%) and during the evaluation of trauma in 103 (28%), abdominal/back pain in 90 (25%), critical illness in 13 (4%), and symptoms of adrenal insufficiency in 5 (1%). Etiologies included postoperative complications in 150 patients (41%), trauma in 107 (30%), coagulopathy in 22 (6%), anticoagulant/antiplatelet therapy in 39 (11%), adrenal neoplasm in 22 (6%), and sepsis in 11, (3%). Overall, 165 patients (46%) were hospitalized, and no deaths occurred due to AH. Median (IQR) baseline AH size was 34 mm (24-40 mm) on the right and 29 mm (22-37 mm) on the left. Among 246 patients with follow-up imaging, AH resolution was complete in 155 (63%) and incomplete in 74 (30%) at a median of 15 months (IQR, 6-31 months). Patients with bilateral AH were more likely to have underlying coagulopathy (44% vs 3%) and to develop primary adrenal insufficiency (72% vs 0%) than those with unilateral AH (P<.001).

CONCLUSION

Often, AH presents as an incidental unilateral lesion with normal adrenal function, commonly attributed to postoperative complications or trauma. In contrast, bilateral AH is rare and typically linked to underlying coagulopathy, with primary adrenal insufficiency developing in most patients.

Clinical presentation and outcomes in patients with antiphospholipid syndrome-associated adrenal hemorrhage. A multicenter cohort study and systematic literature review

BACKGROUND

Adrenal hemorrhage (AH) can occur in patients with antiphospholipid Syndrome (APS). We aimed to characterize the clinical manifestations, treatments, and outcomes of patients presenting with APS-associated AH (APS-AH) through a retrospective cohort and a systematic literature review (SLR).

METHODS

We performed a mixed-source approach combining a multicenter cohort with an SLR of patients with incident APS-AH. We included patients from Mayo Clinic and published cases with persistent positivity for antiphospholipid antibodies and presenting with AH, demonstrated by imaging or biopsy. We extracted demographics, clinical characteristics, laboratory findings, treatment strategies, and outcomes (primary adrenal insufficiency and mortality). We used Kaplan-Meier and Cox models for survival analysis.

RESULTS

We included 256 patients in total, 61 (24%) from Mayo Clinic and 195 (76%) from the SLR. The mean age was 46.8 (SD 15.2) years, and 45% were female. 69% of patients had bilateral adrenal involvement and 64% presented adrenal insufficiency. The most common symptoms at presentation were abdominal pain in 79%, and nausea and vomiting 46%. Hyponatremia (77%) was the most common electrolyte abnormality. Factors associated with primary adrenal insufficiency were bilateral adrenal involvement at initial imaging (OR 3.73, CI; 95%, 1.47-9.46) and anticardiolipin IgG positivity (OR 3.80, CI; 95%, 1.30-11.09). The survival rate at five years was 82%. History of stroke was associated with 3.6-fold increase in mortality (HR 3.62, 95% CI; 1.33-9.85).

CONCLUSION

AH is a severe manifestation of APS with increased mortality. Most patients developed permanent primary adrenal insufficiency, particularly those positive for anticardiolipin IgG and bilateral adrenal involvement.

Spontaneous Contralateral Adrenal Hemorrhage during Periduodenal Abscess Drain Placement

A spontaneous adrenal hemorrhage is a rare complication occurring in the setting of interventional radiology procedures. Here, we present the case of a 73-year-old male who underwent CT-guided drainage of a periduodenal collection. During the procedure, he developed sudden onset left back pain and hypertension, which revealed a left adrenal gland hemorrhage on CT imaging. Potential mechanisms for this complication include a physiological stress response, procedure-associated hypercoagulability, and direct trauma to the adrenal gland. Moreover, an adrenal hemorrhage should be monitored closely as it can lead to severe clinical consequences requiring treatment with IV analgesics and antihypertensives.

Waterhouse-Friderichsen syndrome, septic adrenal apoplexy

Waterhouse-Friderichsen syndrome is a rare but potentially fatal disorder of the adrenal gland characterized by bilateral adrenal hemorrhage. It is classically a result of meningococcal sepsis and presents acutely with features of shock, petechial rashes, abdominal pain, and non-specific symptoms such as headache, fatigue, and vomiting. Treatment consists of fluid resuscitation, corticosteroid replacement, and possibly surgery. The prognosis is poor despite treatment. This chapter will review the etiology, pathogenesis, clinical features, and management of the disease.

Bilateral adrenal hemorrhage: learning notes from clinical practice and literature review

Adrenal hemorrhage is a rare, but important, diagnosis to recognize, in particular when there is involvement of both adrenal glands. Bilateral adrenal hemorrhage can in fact lead to adrenal insufficiency, with dramatic consequences if not promptly recognized and treated. It is normally caused by systemic conditions that lead to the vasoconstriction and thrombosis of the adrenal vein. Oftentimes, the clinical diagnosis of this condition can be very challenging, as its signs and symptoms are generalized and nonspecific (abdominal pain, nausea, and fatigue). Here, we present the cases of two patients admitted to the Emergency Department in 2016 and 2022 with acute abdominal pain, having recently undergone surgery and subsequently prescribed low-molecular-weight heparin. In both cases, laboratory results revealed neutrophilic leukocytosis and an unexplained anemia. Due to the persistence of abdominal pain despite medication, a CT scan was performed, showing an enlargement of both adrenal glands suggestive of bilateral adrenal hemorrhage. Adrenal function was tested that correlated with a diagnosis of adrenal insufficiency, and both patients were promptly treated with parenteral hydrocortisone as a result. On 5 years' follow-up from the acute event, the second patient's adrenal function had returned to normal, and he has not needed further adrenal replacement therapy; the first patient however demonstrated persistence of adrenal failure requiring replacement therapy. In this paper, through our experience and a literature analysis, we will aim to outline some clues to identify patients at potential risk of bilateral adrenal hemorrhage.

Primary adrenal insufficiency due to bilateral adrenal hemorrhage-adrenal infarction in a patient with systemic lupus erythematosus and antiphospholipid syndrome: case presentation and review of the literature

Primary adrenal insufficiency (PAI) is a rare disease which represents the end stage of a destructive process involving the adrenal cortex. Occasionally it may be caused by bilateral adrenal hemorrhagic infarction in patients with antiphospholipid syndrome (APS). We herein report the challenging case of a 30-year-old female patient with systemic lupus erythematosus (SLE) and secondary APS who was admitted to the emergency department (ED) due to fever, lethargy, and syncopal episodes. Hyponatremia, hyperkalemia, hyperpigmentation, shock, altered mental status, and clinical response to glucocorticoid administration were features highly suggestive of an acute adrenal crisis. The patient's clinical status required admission to the intensive care unit (ICU), where steroid replacement, anticoagulation, and supportive therapy were provided, with a good outcome. Imaging demonstrated bilateral adrenal enlargement attributed to recent adrenal hemorrhage. This case highlights the fact that bilateral adrenal vein thrombosis and subsequent hemorrhage can be part of the thromboembolic complications seen in both primary and secondary APS and which, if misdiagnosed, may lead to a life-threatening adrenal crisis. High clinical suspicion is required for its prompt diagnosis and management. A literature search of past clinical cases with adrenal insufficiency (AI) in the setting of APS and SLE was conducted using major electronic databases. Our aim was to retrieve information about the pathophysiology, diagnosis, and management of similar conditions.

Bilateral adrenal hemorrhage after pancreaticoduodenectomy

The incidence of bilateral adrenal hemorrhage (BAH) in the postoperative setting is rare, but potentially life threatening. A literature review of postoperative BAH reveals that there is limited data on BAH following abdominal surgery. We present a case of BAH following pancreaticoduodenectomy, which has not been previously documented in the literature. A 70-year-old male patient with no previous history of adrenal disease underwent an uncomplicated pancreaticoduodenectomy and was discharged after a typical postoperative course. He was readmitted with abdominal pain and ileus on POD 8 and a computed tomography (CT) scan was initially unremarkable, but a repeat CT scan on POD 11 demonstrated BAH. He was found to have adrenal insufficiency and was successfully treated with steroids. Clinicians should be aware of the possibility of adrenal hemorrhage postoperatively as it can potentially be a fatal surgical complication. To enhance patient outcomes, early detection and appropriate treatment are essential.

Approach to the Patient With Adrenal Hemorrhage

Adrenal hemorrhage is an uncommon, underrecognized condition that can be encountered in several clinical contexts. Diagnosing adrenal hemorrhage is challenging due to its nonspecific clinical features. Therefore, it remains a diagnosis that is made serendipitously on imaging of acutely unwell patients rather than with prospective clinical suspicion. Adrenal hemorrhage can follow abdominal trauma or appear on a background of predisposing conditions such as adrenal tumors, sepsis, or coagulopathy. Adrenal hemorrhage is also increasingly reported in patients with COVID-19 infection and in the context of vaccine-induced immune thrombocytopenia and thrombosis. Unexplained abdominal pain with hemodynamic instability in a patient with a predisposing condition should alert the physician to the possibility of adrenal hemorrhage. Bilateral adrenal hemorrhage can lead to adrenal insufficiency and potentially fatal adrenal crisis without timely recognition and treatment. In this article, we highlight the clinical circumstances that are associated with higher risk of adrenal hemorrhage, encouraging clinicians to prospectively consider the diagnosis, and we share a diagnostic and management strategy.

COVID-19-related adrenal haemorrhage: Multicentre UK experience and systematic review of the literature

OBJECTIVE

Adrenal haemorrhage (AH) is an uncommon, usually incidental imaging finding in acutely unwell patients. AH has been reported during coronavirus disease 2019 (COVID-19) infection and following ChAdOx1 nCoV-19 (Oxford-AstraZeneca) vaccination. The Society for Endocrinology (SfE) established a task force to describe the UK experience of COVID-19-related AH.

DESIGN

A systematic literature review was undertaken. A survey was conducted through the SfE clinical membership to identify patients with COVID-19-related AH using a standardized data collection tool.

RESULTS

The literature search yielded 25 cases of COVID-19-related AH (19 bilateral; 13 infection-related, and 12 vaccine-related). Eight UK centres responded to the survey with at least one case. A total of 18 cases were included in the descriptive study, including 11 from the survey and 7 UK-based patients from the systematic review. Seven patients (4 males; median age 53 (range 26-70) years), had infection-related AH (four bilateral). Median time from positive COVID-19 test to AH detection was 8 (range 1-30) days. Eleven cases of vaccine-related AH (eight bilateral) were captured (3 males; median age 47 (range 23-78) years). Median time between vaccination (nine Oxford-AstraZeneca and two Pfizer-BioNTech) and AH was 9 (range 2-27) days; 9/11 AH occurred after the first vaccine dose. Acute abdominal pain was the commonest presentation (72%) in AH of any cause. All 12 patients with bilateral AH and one patient with unilateral AH required glucocorticoid replacement.

CONCLUSION

Adrenal haemorrhage with consequential adrenal insufficiency can be a complication of COVID-19 infection and vaccination. Adrenal function assessment is mandatory to avoid the potentially fatal consequences of unrecognized adrenal insufficiency.

Adrenal Hemorrhage: A Review

Importance

Adrenal hemorrhage in pregnancy is rare. The prevalence of pregnant patients whose pregnancies are complicated by preeclampsia or eclampsia is hypothesized to be slightly higher than the 0.4% to 1.1% occurrence rate in the nonpregnant population. However, the mortality rate of adrenal hemorrhage is reportedly as high as 15%. Therefore, it is critical for obstetric providers to have basic knowledge on the presentation, diagnosis, and management of adrenal hemorrhage in the pregnant population so that prompt diagnosis can be made.

Objective

This review highlights incidence, pathophysiology, risk factors, diagnosis, management, and complications of adrenal hemorrhage in the peripartum period.

Evidence Acquisition

A literature search was undertaken by our research university librarian using the search engines of PubMed, CINAHL, and EMBASE (Medline items removed). The search terms used included "adrenal hemorrhage" OR "adrenal gland hemorrhage" AND "pregnancy" OR "maternal." The search was limited to articles in English, and the years searched were from January 1, 2015 to December 31, 2021.

Results

There were 130 abstracts identified, and 30 of the articles were ultimately used as the basis for this review. Presenting signs and symptoms of adrenal hemorrhage were typically abdominal, back, and flank pain. Diagnosis was typically made with ultrasound and computed tomography or magnetic resonance imaging without contrast for confirmation. Management options include conservative management versus surgical management with adrenalectomy or interventional radiology embolization in the unstable patient. For patients with evidence of adrenal insufficiency, steroid replacement was used. Most patients with adrenal hemorrhage in the literature had unilateral adrenal hemorrhage; however, several cases of bilateral adrenal hemorrhage have been reported. Patients with bilateral adrenal hemorrhage were more likely to require steroids for adrenal insufficiency. There are no known contraindications to vaginal delivery in this group of patients, and patients who were managed conservatively were often able to continue the pregnancy to term.

Conclusions

Early recognition and management are integral in decreasing the morbidity and mortality associated with adrenal hemorrhage.

Relevance Statement

This is an evidence-based review of adrenal hemorrhage in pregnancy and how to diagnose and manage a pregnancy complicated by adrenal hemorrhage.

Multimodality imaging of adrenal gland pathologies: A comprehensive pictorial review

The assessment of acute abdominal and pelvic emergencies typically involves a multimodal approach consisting of plain radiographs, ultrasound, computed tomography (CT), and rarely magnetic resonance imaging (MRI). Although MRI is not traditionally employed in acute care settings, there are several instances in which MRI provides superior functional and prognostic information. In this manuscript, we highlight multimodal findings of adrenal gland emergencies: Hemorrhage, infarction, and infection. The purpose of our study is to highlight significant findings in various modalities, including CT, MRI, ultrasound, and PET/CT. Due to the scarcity of published data and limited clinical use, primary ultrasound findings are limited in our multimodal review. In conclusion, we find that synergistic use of CT, MRI, and functional imaging provides an effective tool for evaluation and management of adrenal pathology.

Multimodality Imaging Findings in Waterhouse-Friderichsen Syndrome: A Case Report and a Short Literature Review

Waterhouse-Friderichsen syndrome is a rare disease characterized by bleeding into the adrenal glands, and its symptoms may vary from non-specific abdominal pain to multi-organ failure. Commonly related to a variety of infectious diseases among which sepsis from Neisseria meningitidis is the most frequent, many other etiologies have been described, and in some rare cases, even no apparent cause can be identified. We report a rare case of an idiopathic bilateral adrenal hemorrhage in a 70-year-old male who presented to our emergency department with non-specific abdominal pain. Ultrasonography Scan (US) and Computed Tomography (CT) findings were crucial for making an early diagnosis, which resulted in a short hospitalization time and, eventually, a complete recovery of the adrenal function. After discharge, Magnetic Resonance Imaging (MRI) was also performed, providing a more complete ensemble of multimodality imaging findings that can be associated with this rare syndrome.

Presumptive nontraumatic adrenal hemorrhage preceding hypoadrenocorticism in a dog

Nontraumatic adrenal hemorrhage (NTAH) has been associated with stress-induced catecholamines release in underlying conditions such as sepsis and recent surgery in humans. It can lead to primary hypoadrenocorticism (HOAC) when both adrenal glands are involved, with nonspecific clinical signs and laboratory findings that can lead to a missed diagnosis. Bilateral thickening of the adrenal glands with periadrenal fat stranding was identified in a 10-year-old male Maltese dog after abdominal surgery. The dog showed clinical signs and biochemical changes consistent with HOAC, but treatment for presumed critical illness-related corticosteroid insufficiency was initiated. Clinical signs relapsed with a 3-week dose reduction of hydrocortisone, and a reduction in adrenal size was observed on follow-up ultrasound examination. Hormonal testing confirmed HOAC in the dog. To the best of our knowledge, HOAC caused by spontaneous NTAH has not been reported in the veterinary literature. This report describes a dog that developed HOAC with presumed adrenal atrophy after suspected spontaneous bilateral NTAH.

Bilateral Adrenal Hemorrhage Following Femoral Hip Hemiarthroplasty: A Case Report

Bilateral adrenal hemorrhage (BAH) is a rare and potentially fatal complication following total hip arthroplasty and low-molecule heparin use for DVT-prophylaxis. We present a case of a 64-year-old woman who sustained a femoral neck fracture, which was addressed with hip hemiarthroplasty. Twelve days postoperatively DVT was diagnosed and therapeutic doses of low-molecule-heparin were administered. The next day, CTPA was done searching for pulmonary embolism but BAH was shown and a short synacthen test confirmed the diagnosis of adrenal insufficiency. A therapeutic protocol with hydrocortisone was followed.

Bilateral Adrenal Hemorrhage and Adrenal Insufficiency in the Context of Polycythemia Vera: A Case Report and Review of the Literature

Background

Polycythemia vera (PV) is a myeloproliferative disorder presented with different manifestations. However, bilateral adrenal hemorrhage (BAH) and adrenal insufficiency (AI) are rare manifestations. Herein, we described a patient who suffered from BAH and AI in the context of PV. Case Presentation. A 60-year-old man with an underlying history of PV was admitted with severe abdominal pain, nausea, and loss of consciousness. Primitive computed tomography (CT) scan findings revealed bilateral adrenal masses (right: 40 ∗ 23 mm, left: 60 ∗ 35 mm) with the second scan showing quite similar results (right adrenal: 40 ∗ 29 mm, left adrenal: 48 ∗ 26 mm) suggesting BAH. The further adrenal assessment proved concurrent AI. Both adrenal masses resolved completely after 15 months. However, the patient still suffered from AI.

Conclusion

BAH and AI in patients with PV should be considered rare complications requiring high clinical suspicion for early diagnosis and treatment to avoid life-threatening outcomes.

Unilateral Adrenal Hemorrhage: A Rare Complication of Anticoagulant Use

Unilateral adrenal hemorrhage is a rare but deadly complication that can occur secondary to causes such as trauma and metastasis. A 55-year-old male with a history of metastatic lung adenocarcinoma and deep vein thrombosis managed with rivaroxaban presented with acute right abdominal and flank pain. A CT angiogram of the abdomen showed a retroperitoneal hematoma around the right adrenal gland, consistent with a unilateral adrenal hemorrhage. An MRI showed no signs of adrenal metastasis and the patient had no history of trauma. The volume of the hematoma did not change in size and the patient was hemodynamically stable, which only prompted supportive management. Anticoagulant use is a known risk factor for bilateral adrenal hemorrhage. However, this case demonstrates that unilateral adrenal hemorrhage can also be a complication, one that usually appears subclinically. It can present non-specifically but may progress to a more fatal bilateral hemorrhage. Hence, it demands a high index of suspicion for patients on systemic anticoagulation.

A case of ChAdOx1 vaccine-induced thrombocytopenia and thrombosis syndrome leading to bilateral adrenal haemorrhage and adrenal insufficiency

Summary

Vaccine-induced thrombosis and thrombocytopenia (VITT) after vaccination against SARS-CoV-2 with the adenoviral vector-based vaccines ChAdOx1 and Ad26.COV2.S has been associated with adrenal pathology, such as bilateral adrenal vein thrombosis, adrenal cortex haemorrhage and adrenal insufficiency in 6% of patients. We report the case of a 23-year-old woman who presented at 8 days after ChAdOx1 vaccination with a low platelet count of 43 × 109/L, raised d dimers >100 000 ng/mL and multiple lobar and segmental pulmonary emboli. Anti-platelet factor 4 antibodies were detected confirming definite VITT in accordance with the UK diagneostic criteria. At 16 days post-vaccine, further imaging showed bilateral adrenal haemorrhage, non-occlusive splenic vein thrombosis and right ventricular thrombosis. Her cortisol level was <25 nmol/L. She was treated with anticoagulation, plasmapheresis, immunosuppression and steroid replacement. She had high anti-spike titre and positive anti-nucleocapsid titres for SARS-CoV-2. She developed seizures secondary to posterior reversible encephalopathy, requiring intensive care. After 4 weeks in hospital, she was discharged on warfarin, hydrocortisone and fludrocortisone replacement. Short synacthen tests 3 and 9 months later showed no recovery of adrenal function, although magnetic resonance imaging of the adrenal glands showed resolving adrenal haemorrhage. Adrenal insufficiency secondary to bilateral adrenal vein thrombosis and adrenal haemorrhage should be suspected in patients with VITT and treated promptly. Adrenal vein thrombosis can occur either as the initial presentation of VITT or days to weeks after the development of thrombosis in other sites. Further studies are required to provide insight on adrenal function recovery after VITT.

Learning points

Adrenal insufficiency secondary to bilateral adrenal vein thrombosis and adrenal cortex haemorrhage should be suspected in patients with vaccine-induced thrombosis and thrombocytopenia (VITT) and treated promptly. Adrenal vein thrombosis can occur as the initial presentation of VITT or even days to weeks later after the development of thrombosis in other more classic sites (e.g. pulmonary or cerebral vasculature). Completion of vaccination schedule against SARS-CoV-2 post-VITT using an mRNA-based vaccine should be recommended to patients post-VITT as mRNA-based vaccines have not been associated with VITT but confer protection against SARS-CoV-2. There is paucity of data regarding the potential for recovery of adrenal function after bilateral adrenal haemorrhage in the context of VITT, and thus, more studies are needed to inform clinical practice. The need for disease registries for rare conditions, such as VITT, is crucial as direct cooperation and sharing of information by clinicians might enable quicker identification of disease patterns than would have been possible via established reporting tools of adverse events.

Adrenal bleeding due to pheochromocytoma - A call for algorithm

BACKGROUND

Adrenal hemorrhage is a rare, usually life-threating complication. The most common neoplasm resulting in spontaneous adrenal bleeding is pheochromocytoma and it accounts for nearly 50% of cases. Currently, the recommendations for the diagnosis and management of patients with adrenal bleeding due to pheochromocytoma are unavailable.

MATERIALS AND METHODS

We performed a database search for all pheochromocytoma patients, diagnosed and treated from 2005 to 2021 in tertiary endocrinology center. 206 patients were identified, 183 with complete data were included in the analysis. We investigated clinicopathological characteristics, treatment and outcomes of hemorrhagic pheochromocytoma cases and characterize our approach to perioperative diagnosis and medical management. Finally our experiences and data from previously published articles concerning adrenal hemorrhage were analyzed to propose a diagnostic and therapeutic algorithm for hemorrhagic pheochromocytomas.

RESULTS

In the whole group, seven patients (4 men and 3 women) with adrenal bleeding were found, (3.8%). Median patient's age was 49 years (range: 36-78 years). The most common manifestation of adrenal bleeding was acute abdominal pain (5/7). Two patients developed shock. Hormonal assessment was performed in five patients, based on 24-hour urinary fractionated metanephrines with urinary 3-methoxytyramine. Normetanephrine was elevated in all patients, metanephrine and 3-methoxytyramine - in four cases (4/5). Most patients (6/7) had symptoms suggesting pheochromocytoma before hemorrhage - most commonly paroxysmal hypertension (4/7). One patient died, before the diagnosis of adrenal bleeding was made. Diagnostic imaging performed in six out of seven patients revealed adrenal tumor, with median largest diameter equal to 7.4 cm (range: 5-11 cm). Five patients had elective surgery, in one case an urgent surgery was performed. In all cases the diagnosis of pheochromocytoma was confirmed in postoperative histopathology or in autopsy. The perioperative survival rate was 85.7%.

CONCLUSIONS

Diagnosis of pheochromocytoma should be always considered in patients with adrenal bleeding, especially with accompanying abdominal pain, hemodynamic shock and previous history of pheochromocytoma-associated symptoms. Lack of proper diagnosis of pheochromocytoma before surgery is associated with an additional perioperative risk. To improve the decision making in this life-threatening clinical situation, based on our results and literature data, we proposed a diagnostic and treatment algorithm.

Waterhouse-Friderichsen syndrome in a cat with Klebsiella spp. infection

OBJECTIVE

To describe a case of Waterhouse-Friderichsen syndrome of adrenocortical failure in a cat with Klebsiella spp. infection.

CASE SUMMARY

A 12-year-old male neutered domestic short-haired cat was referred for respiratory failure requiring mechanical ventilation. The cat remained comatose despite successful weaning from the ventilator and developed a Klebsiella pneumoniae pneumonia. On day 4 of hospitalization, the cat acutely deteriorated with profound hypotension, azotemia, and hyperkalemia, which rapidly progressed to cardiac arrest. Necropsy findings revealed massive adrenal hemorrhage and intralesional bacteria, termed Waterhouse-Friderichsen syndrome. Waterhouse-Friderichsen syndrome was suspected to have been the cause of acquired adrenocortical insufficiency and sudden death of the cat.

NEW OR UNIQUE INFORMATION

To the authors' knowledge, this is the first report of sepsis causing Waterhouse-Friderichsen syndrome in a veterinary species.

Vanishing Adrenal Mass in Pregnancy

Objectives

The evaluation of an adrenal mass is challenging. We present the case of a 33-year-old pregnant woman who was found to have an adrenal incidentaloma. Four months after the initial imaging, the mass vanished.

Methods

We described the case of a pregnant woman with hypertension and an incidentally found right adrenal mass.

Results

A magnetic resonance imaging scan showed a right adrenal mass measuring 7.9 × 3.9 × 3.0 cm with a multilobulated appearance. Initial biochemical testing was concerning for a pheochromocytoma with positive metanephrines during hospitalization while being treated for an infection. Repeat outpatient adrenal hormone results, including metanephrines, were negative. Four months after her initial magnetic resonance imaging scan, the right adrenal mass was no longer present.

Conclusion

A 33-year-old pregnant woman was found to have a right adrenal mass that later vanished as a result of the resolution of a unilateral adrenal hemorrhage. Predisposing factors to adrenal hemorrhage in the presented case include pregnancy, infection, and hypertension.

[Spontaneous adrenal hematomas. Retrospective analysis of 20 cases from a tertiary center]

INTRODUCTION

Spontaneous adrenal hemorrhages (AH) are a rare condition with no consensus about their management.

METHODS

Patients were identified using the Medicalization of the Information System Program database, imaging software and a call for observations to internists, intensivists and obsetricians working at our institution. Adult patients whose medical records were complete and whose diagnosis was confirmed by medical imaging were included.

RESULTS

From 2000 to 2007, 20 patients were identified, including 15 were women. The clinical onset of AH was non-specific. In five cases, AH occurred during pregnancy; four of them were unilateral and right sided. The etiology of the other fifteen (bilateral adrenal hemorrhage in 11) were as follows: antiphospholipid syndrome (n=8), heparin-induced thrombocytopenia (n=4), essential thrombocythemia (n=3), spontaneous AH due to oral anticoagulants (n=1), complication of a surgical act (n=3), and sepsis (n=3). In seven cases, two causes were concomitant. The diagnosis of AH was often confirmed by abdominal CT. An anticoagulant treatment was initiated in 16 cases. Ten of the eleven patients presenting with bilateral adrenal hematomas were treated using a long-term substitute opotherapy. One patient died because of a catastrophic antiphospholipid syndrome.

CONCLUSION

The clinical onset of HS is heterogeneous and non-specific. The confirmatory diagnosis is often based on abdominal CT. The search for an underlying acquired thrombophilia is essential and we found in this study etiological data comparable to the main series in the literature. Adrenal insufficiency is most of the time definitive in cases of bilateral involvement.

Haemorrhagic shock from solid tumours of the adrenal gland: a case of bleeding primary adrenal lymphoma

Suprarenal or adrenal gland haemorrhage is an uncommon but potentially lethal condition if unrecognised. Adrenal masses rarely present with haemorrhage, but they remain an important differential aetiology for adrenal bleeding. We present a novel case of primary adrenal lymphoma with adrenal haemorrhage in a middle-aged woman who presented with right-sided abdominal pain and class 1 haemorrhagic shock. She was found to have spontaneous unilateral adrenal gland haemorrhage in the absence of any underlying previous pathology. Presenting features, diagnosis and subsequent oncological management are reported.

Adrenal Hemorrhage in a Cortisol-Secreting Adenoma Caused by Antiphospholipid Syndrome Revealed by Clinical and Pathological Investigations: A Case Report

Due to its rarity, adrenal hemorrhage is difficult to diagnose, and its precise etiology has remained unknown. One of the pivotal mechanisms of adrenal hemorrhage is the thrombosis of the adrenal vein, which could be due to thrombophilia. However, detailed pathological evaluation of resected adrenal glands is usually required for definitive diagnosis. Here, we report a case of a cortisol-secreting adenoma with concomitant foci of hemorrhage due to antiphospholipid syndrome diagnosed both clinically and pathologically. In addition, the tumor in this case was pathologically diagnosed as cortisol-secreting adenoma, although the patient did not necessarily fulfill the clinical diagnostic criteria of full-blown Cushing or sub-clinical Cushing syndrome during the clinical course, which also did highlight the importance of detailed histopathological investigations of resected adrenocortical lesions.

Adrenal haemorrhage as a complication of COVID-19 infection

We report an unusual complication of COVID-19 infection in a 53-year-old Caucasian man. He presented with shortness of breath, fever and pleuritic chest pain. A CT pulmonary angiogram (CTPA) demonstrated acute bilateral pulmonary embolism and bilateral multifocal parenchymal ground glass change consistent with COVID-19 (SARS-CoV-2) infection. Right adrenal haemorrhage was suspected on the CTPA which was confirmed on triple-phase abdominal CT imaging. A short Synacthen test revealed normal adrenal function. He was treated initially with an intravenous heparin infusion, which was changed to apixaban with a planned outpatient review in 3 months’ time. He made an uncomplicated recovery and was discharged. Follow-up imaging nearly 5 months later showed near complete resolution of the right adrenal haemorrhage with no CT evidence of an underlying adrenal lesion.

Rare Bilateral Adrenal Haemorrhage with Addisonian Crisis: When Risk Factors Come in Droves

Addisonian crisis is the life-threatening acute manifestation of adrenal insufficiency due to absolute or relative glucocorticoid deficiency. Adrenal haemorrhage is a rare condition of unknown incidence with the risk of adrenal insufficiency and death, not uncommonly first being diagnosed on the pathologists table. We report the case of a 68-year-old female patient with respiratory tract infection suffering acute life-threatening adrenal insufficiency caused by bilateral adrenal haemorrhages following orthopedic surgery while taking anticoagulation therapy. The patient rapidly deteriorated with hypotension, showing how important it is to consider a possible Addisonian crisis when this scenario occurs, especially with precipitating factors such as anticoagulant therapy, sepsis, or surgery.

Thrombocytopenia, Anasarca, Fever, Reticulin Fibrosis/Renal Failure, and Organomegaly (TAFRO) Syndrome with Bilateral Adrenal Hemorrhage in Two Caucasian Patients

Case series

Patients: Male, 19-year-old • Female, 31-year-old

Final Diagnosis: TAFRO syndrome

Symptoms: Fever • splenomegaly • lymphadenopathies

Medication: —

Clinical Procedure: —

Specialty: Hematology

ADRENAL INSUFFICIENCY SECONDARY TO BILATERAL ADRENAL HEMORRHAGE ASSOCIATED WITH ANTIPHOSPHOLIPID SYNDROME

OBJECTIVE

Antiphospholipid syndrome (APS) can involve multiple organ systems but endocrine manifestations are rare. In most cases adrenal insufficiency (AI) is the first endocrine manifestation of APS. The prompt diagnosis of AI is critical as this disorder is a life-threatening disease that may lead to fatal outcomes if left untreated. We present a case of AI associated with APS the patient was diagnosed promptly and managed successfully.

METHODS

The diagnosis of APS was based on a combination of clinical features (deep venous thrombosis and pulmonary embolism) and laboratory findings (lupus anticoagulant, anticardiolipin antibody, anti-beta-2 glycoprotein-I antibody), without alternative diagnosis to explain the clinical findings. AI was diagnosed by low morning serum cortisol with elevated adrenocorticotropic hormone (ACTH) level as well as an ACTH stimulation test.

RESULTS

A 50-year-old male presented with deep venous thrombosis of the left extremity diagnosed by compressive ultrasound, and was subsequently diagnosed with a pulmonary embolism by computed tomography angiography and treated with heparin. Two days later, he developed hypotension and bilateral flank pain, and an abdominal computed tomography scan revealed bilateral adrenal hemorrhage. Laboratory results showed a serum cortisol of 3.3 mcg/dL (stress normal, 25 to 35 mcg/dL) and ACTH of 319 pg/mL (stress normal, 128 to 218 pg/mL), consistent with primary AI. Symptoms improved quickly with hydrocortisone therapy. The patient still required glucocorticoid therapy for at least 4 years thereafter.

CONCLUSION

In all cases of adrenal hemorrhage and infarction with unknown etiology, screening with lupus anticoagulant and anticardiolipin antibodies is imperative. Recognition of this high-mortality condition allows for appropriate screening and confirmatory tests leading to a prompt diagnosis and timely management.

Spontaneous adrenal hemorrhage and preeclampsia: A case report

Spontaneous Adrenal Hemorrhage is a rare disease. It's one of the rare causes of abdominal pain late in pregnancy. I present a case with near term Spontaneous Adrenal Hemorrhage and concurrent severe preeclampsia, aiming to address the anesthetic considerations and management of such challenging presentation.

Rivaroxaban Related Bilateral Adrenal Hemorrhage: A Rare Complications of Direct Oral Anticoagulants - A Case Reports

BACKGROUND Adrenal hemorrhage is an uncommon and under-recognized disorder with a wide array of etiologies ranging from pregnancy to septic shock. It is one of the complications of anticoagulation therapy, including direct anticoagulant medications. CASE REPORT Here, we present a case of a 68-year-old female with recent right knee arthroplasty who was on rivaroxaban for deep vein thrombosis (DVT) prophylaxis presented to the emergency department (ED) for severe acute onset abdominal pain, computed tomography (CT) of abdomen and pelvis revealed possible left adrenal hemorrhage that was confirmed with magnetic resonance imaging (MRI). On repeat CT, her unilateral adrenal hemorrhage converted to a bilateral adrenal hemorrhage (BAH) and, as a result, the patient developed adrenal insufficiency. CONCLUSIONS An undiagnosed and untreated adrenal hemorrhage can have catastrophic consequences, leading to adrenal insufficiency with potential shock and death. Therefore, it is important for clinicians to have an increased awareness and knowledge about adrenal hemorrhage.

Unilateral nonhaemorrhagic adrenal infarction as a cause of abdominal pain during pregnancy

Adrenal infarction is usually associated with bilateral adrenal hemorrhage in the setting of antiphospholipid syndrome or hemodynamic variation. Few cases of unilateral nonhemorrhagic adrenal infarction (NHAI) have been described in the literature. Here, we report a case occurring during pregnancy. A 30-year-old woman presented at 32 weeks of gestation with sudden-onset right abdominal pain and contractions. Unilateral adrenal infarction was diagnosed following computed tomography (CT). It showed an enlarged right adrenal, without hyperenhancement. Because of persisting contractions, despite medical care, she delivered a healthy, albeit premature, girl. Abdominal pain decreased right after delivery. Three month later, CT imaging showed atrophy of the right adrenal and a normal left adrenal. The patient's adrenal hormonal function was normal. Accurate diagnosis of NHAI remains difficult as its clinical presentation is not specific. It can only be performed with adrenal imaging. Magnetic resonance imaging shows diffuse enlargement of one or both adrenals and an edema on T2-weighted images. Anticoagulation therapy may be discussed. Patients should be evaluated between 3 and 6 months after the event to assess adrenal size and function. In summary, NHAI during pregnancy is probably underdiagnosed and obstetricians should be aware of this or diagnostic difficulty.

Unilateral adrenal hematoma with associated giant mass: a report of two cases

Background: Adrenal hematoma is a rare yet potentially life-threatening event that occurs both in traumatic conditions and in a variety of nontraumatic conditions. In the present study, we report the two cases with idiopathic unilateral adrenal hematoma. Case presentation: Case 1 involved a 72-year-old man who was complaining of upper abdominal pain. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) demonstrated a giant mixed density tumor in the right retroperitoneal space. To remove the tumor, we carried out an adrenalectomy on the right adrenal gland, resecting a specimen measuring 15 × 13.5 cm. The histopathological findings of the specimen revealed a hematoma with normal adrenal tissue. Case 2 involved a 53-year-old woman who complained of an uncomfortable feeling in her left upper abdomen. A retroperitoneal tumor had formed a multicystic lesion and resected because the left renal vein had become compressed. The resected specimen was 10.5 × 10 cm in size and revealed an adrenal hematoma. In the absence of any obvious etiology, the diagnoses in both cases were idiopathic adrenal hematoma. Conclusion: An accurate diagnosis of idiopathic adrenal hematoma is quite difficult to make prior to surgery. Some imaging modalities are useful in generating a differential diagnosis.

The importance of the postmortem interval for the diagnosis of Waterhouse-Friderichsen syndrome by Neisseria meningitidis in a series of forensic cases

The effective value of microbiological post-mortem examinations stands as fundamental in forensic cases involving microbiology. We ran these analyses on five victims, who suddenly died after showing persistent fever. The examinations were conducted between 48 hours and 10 days after death, and adrenal gland apoplexy was detected in all the cases.

Microbiological examinations identified Neisseria meningitidis, which was accountable for Waterhouse–Friderichsen syndrome. Diplococci were isolated from three cadavers that underwent forensic dissection between 2 and 3 days after death. The remaining two cadavers showed polymicrobial contamination, and a polymerase chain reaction technique was necessary to identify the pathogen.

We assumed that the microbial overlap could lead to diagnostic mistakes and conceal the identification of the lethal pathogen. Therefore, we suggest using molecular techniques for a postmortem interval (PMI) longer than 72 hours. Classical microbiological examination should be performed for PMI within 72 hours.

Adrenal Hemorrhage in a Patient Anticoagulated with Apixaban with Antiphospholipid Syndrome

Atraumatic adrenal hemorrhage is a rare injury, often due to the disruption of normal hemostasis secondary to sepsis, autoimmune disease, or chronic anticoagulation. We present a case of recurrent adrenal hemorrhage in a patient with antiphospholipid syndrome previously maintained on warfarin for deep vein thrombosis and pulmonary embolism prophylaxis who worsened shortly after transition to apixaban therapy. Initial left-sided adrenal hemorrhage occurred four weeks after beginning apixaban, followed by the development of retinal hemorrhage and later right-sided adrenal hemorrhage. This is, to date, the first reported case of adrenal hemorrhage in a patient receiving chronic anticoagulation with apixaban.

Acute spontaneous unilateral adrenal hemorrhage: etiology and imaging findings in six cases

Objective

To evaluate the computed tomography characteristics of patients admitted with clinical suspicion of acute adrenal hemorrhage at three centers over a 3-year period and in whom that diagnosis was ultimately confirmed.

Materials and Methods

This was a retrospective analysis of computed tomography findings in patients with suspected acute adrenal hemorrhage. We included only those cases in which the diagnosis was confirmed. Patients with aortic rupture and retroperitoneal hemorrhage were excluded. The images were analyzed by an experienced radiologist and by two radiology residents.

Results

Six cases of unilateral adrenal hemorrhage (three on the left and three on the right) were analyzed. On computed tomography, each appeared as a rounded, oval mass altering the usual anatomy of the adrenal gland. The maximum diameter was 12.2 cm, and attenuation ranged from 45 to 70 HU. There was no appreciable contrast enhancement. No calcifications were observed.

Conclusion

Adrenal hemorrhage, albeit rare, is potentially fatal. Early diagnosis is essential. Therefore, recognition of the possible presentations of these lesions by radiologists may help prevent hemorrhage from progressing to adrenal insufficiency and death.

ADRENAL INSUFFICIENCY FROM UNILATERAL ADRENAL HEMORRHAGE IN A PATIENT ON RIVAROXABAN THROMBOPROPHYLAXIS

Objective

We report a case of unilateral adrenal hemorrhage resulting in adrenal insufficiency in a patient on rivaroxaban for thromboprophylaxis after total knee arthroplasty.

Methods

The clinical presentation, laboratory findings, and outcome of the case are described. An overview of the etiology, diagnosis, and treatment of adrenal hemorrhage is reviewed.

Results

A 61-year-old male underwent bilateral total knee replacements and postoperatively was started on rivaroxaban at 10 mg daily for thromboprophylaxis. About 2 weeks after the procedure, the patient presented with abdominal pain, nausea, vomiting, and generalized weakness. Abdominal computed tomography scan identified an ill-defined heterogeneous density in the left supra-renal fossa, and an abdominal magnetic resonance imaging scan identified diffuse thickening of the left adrenal gland with periadrenal fat stranding suggestive of adrenal hemorrhage. Adrenal insufficiency was suspected and confirmed with a cosyntropin stimulation test. Pre-stimulus cortisol level was 2.7 μg/dL and 60 minutes after cosyntropin administration it was 2.5 μg/dL. The patient was started on intravenous hydrocortisone at 100 mg every 6 hours with improvement of symptoms and discharged on oral hydrocortisone at 20 mg twice daily. Follow up abdominal magnetic resonance imaging 6 weeks after discharge demonstrated resolution of the left adrenal hemorrhage.

Conclusion

A high clinical suspicion and early detection of adrenal hemorrhage in a patient on anticoagulation can allow for earlier intervention and improved outcomes.

Russell's Viper Envenomation-Associated Addisonian Crisis

Snakebite envenomation is an important public health problem in tropical countries. We report a case of bilateral adrenal hemorrhage in a 28-y-old man with Russell's viper bite that occurred in the Sathyamangalam forest range in the Indian state of Tamil Nadu. In this case, a combination of early bite recognition, hospital-based supportive care, corticosteroid therapy, and timely administration of polyvalent antivenom resulted in a favorable clinical outcome.

Acute non-traumatic adrenal haemorrhage-management, pathology and clinical outcomes

Background

Acute adrenal haemorrhage is a rare medical emergency. The aim of the series was to study the clinical presentation and management of patients presenting with acute non-traumatic adrenal haemorrhage.

Methods

The records of patients presenting with an acute abdomen secondary to adrenal haemorrhage and treated in a tertiary endocrine surgical unit over a period of 6 years were reviewed.

Results

Of the 11 included patients, there were 4 males and 7 females; the median [range] age at presentation was 58 [27-89] years. All were initially managed conservatively for bleeding, except one who underwent angioembolisation to ensure hemodynamic stability. Two patients underwent percutaneous drainage of persistent collection and suspected sepsis. Biochemical workup showed hyper function with metanephrine excess in 1 patient. Adrenalectomy was performed in 5 patients after a median [range] of 10 [7-11] weeks. Histology showed benign pathology in 2 patients, malignant in 2 patients and necrotic tumour in 1 patient. Two patients died of disseminated metastatic disease at 5 and 2 months after presentation with bleeding. Conservative management in the other 3 patients was successful at a median follow up of 26 [6-66] months.

Conclusions

Acute adrenal haemorrhage is usually associated with an underlying pathology; which may be benign or malignant; functional or non-functional. Initial conservative management is preferred as it allows determination of functional status and elective surgery, if necessary.

Spontaneous adrenal hemorrhage. Report of two cases and review of pathogenesis, diagnosis and management

Adrenal hemorrhage represents a relatively rare condition, usually associated with meningococcal septicemia. It is an underestimated cause of acute decompensation, multiorgan failure and death, usually diagnosed post-mortem. Depending on its etiology adrenal hemorrhage is categorized as traumatic and non-traumatic. The technical advancement of imaging modalities, has made diagnosis and management more efficient. Assessment of hemodynamic stability, exclusion of a hormonal active adrenal tumor and assessment for adrenal insuffi¬ciency, are of cardinal importance. Angiographic embolization has contributed significantly in better outcomes as emergency laparotomy is associated with high morbidity and mortality rates. Hereby we present two cases of spontaneous adrenal hemorrhage associated with extensive retroperitoneal bleeding and hemodynamic instability. Both underwent angiography with one requiring embolization with favorable outcome. Investigation for exclusion of underlying adrenal tumor, adrenal insufficiency and follow-up imaging are presented in detail for both cases.

Acute Primary Adrenal Insufficiency after Hip Replacement in a Patient with Acute Intermittent Porphyria

Adrenal insufficiency is a potentially life-threatening condition when it occurs acutely, as in adrenal hemorrhage. Generally it is not reversible and requires chronic replacement therapy. Acute intermittent porphyria (AIP) is a rare genetic disease characterized by alterations in heme biosynthesis that result in accumulation of precursors in tissues. A crisis can be triggered by many conditions such as surgery and infections. Symptoms are similar to those of acute hypoadrenalism. Moreover, both conditions are characterized by hyponatremia. We describe the case of a postmenopausal woman known to be affected by AIP who developed after surgery a primary adrenal insufficiency associated with adrenal enlargement; the latter completely reverted in six months.