Two cases of atraumatic adrenal hemorrhage: A review of active management, conservative management, and challenges faced

Adrenal hemorrhage (AH) is an uncommon and potentially disastrous affliction that carries an accepted mortality risk of 15%. Variable symptomatology can cause a diagnostic dilemma and may be missed. We present 2 cases of right-sided AH; both cases were initially presumed to be renal colic. Case 1 was an 86-year-old gentleman, presenting with right flank pain found to have a right-sided atraumatic AH. He presented with hemorrhagic shock, requiring angioembolization of the bleeding vessel. Case 2 was a 62-year-old gentleman who presented with right flank pain and was found to have a right-sided atraumatic AH. He was hemodynamically stable and successfully managed conservatively. Adrenal hemorrhage is a potentially fatal affliction that may be missed. CT scans are the recommended imaging modality during an acute presentation due to wider availability and fast assessment. We demonstrate a hemodynamically stable patient managed with a 'watch and wait' approach and an unstable patient managed with resuscitation followed by urgent angioembolization.

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.

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.

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: A rare presentation of catastrophic anti-phospholipid syndrome

Catastrophic anti-phospholipid syndrome (CAPS) is characterized by microvascular thrombosis in multiple sites leading to multi-organ damage. It is a rare and fatal complication of antiphospholipid syndrome (APS). We present a rare case of CAPS that presented with bilateral (b/l) adrenal hemorrhage making the diagnosis challenging in this otherwise rare disease. A 51-year-old female was initially admitted with abdominal pain and found to have bilateral adrenal hemorrhage. Patient had a fulminant disease course in which she had thrombotic manifestations involving multiple organ systems. This case was especially challenging as the patient's bilateral adrenal hemorrhage was the first manifestation of CAPS; the diagnosis of APS had to be made while treatment for presumed CAPS was emergently commenced for this life-threatening disease. Key to managing this condition is having a high index of suspicion for the diagnosis in patients presenting with multi-organ failure and multiple thromboses and hemorrhage.

Adrenal hemorrhage following direct oral anticoagulant (DOAC) therapy: two case reports and literature review

Background

Adrenal hemorrhage (AH) is a rare condition that can result in a life-threatening medical emergency. This medical condition could be caused by several underlying factors, one of which is the use of anticoagulants. As far as we are aware, direct oral anticoagulant (DOAC) agents are a rare but possible cause of AH.

Case presentation

Herein, we described two cases of AH due to DOACs. The first case was a 35-year-old Iranian woman with a past medical history of Hashimoto thyroiditis who was being treated with apixaban due to the previous thrombosis. Her first symptoms of AH (November 2021) were strangely similar to symptoms of autoimmune Addison disease (AAD) which led to a confirmed diagnosis of autoimmune polyendocrine syndrome type 2 (APS-2). An abdominal MRI revealed an oval shape well-encapsulated cystic mass with a diameter of 20 × 14 mm with a thick and low signal intensity rim in the left adrenal gland, highly suggestive of sub-acute left-sided AH. Our second case was an 89-year-old Iranian woman who had been admitted to the hospital (August 2021) with low blood pressure and disorientation. At the beginning of her admission, the evaluation showed hyponatremia, and further evaluations confirmed adrenal insufficiency (AI). The patient reported rivaroxaban usage for deep vein thrombosis prophylaxis after femur fixation surgery. Her abdominal CT scans showed bilateral adrenal masses highly suggestive of AH. Her follow-up examination showed persistent AI after three months.

Conclusion

Given the history of our cases, physicians should be aware of AH in patients receiving DOACs, particularly in elderly patients who are at high risk of bleeding. It is also worth noting that AH can occur in any patient with any medical history and history of DOAC use, which is why patients must be closely monitored.

Bilateral adrenal hemorrhage in a man with severe COVID-19 pneumonia

This case report demonstrates bilateral adrenal hemorrhage in a fifty-year old man with severe COVID-19 pneumonia. We discuss how adrenal hemorrhage can be one of the possible complications of COVID-19. The case also shows how adrenal hemorrhage can be diagnosed incidentally in a scan performed for a different reason given the difficulty of clinical diagnosis and the non-specific clinical presentation.

Prenatal Imaging Diagnosis of Suprarenal Lesions

INTRODUCTION

Prenatal suprarenal lesions represent diverse pathologies. This study investigated prenatal imaging features and regression patterns associated with specific lesion diagnoses.

METHODS

This is a multicenter retrospective review of fetuses with prenatally diagnosed suprarenal lesions between 2001 and 2019. Prenatal ultrasound and MRI characteristics, postnatal imaging, and clinical course were reviewed. Prenatal imaging findings were compared by the most common diagnoses and regression patterns.

RESULTS

Forty-four fetuses were prenatally diagnosed with suprarenal lesions. Diagnoses included pulmonary sequestration (n = 12; 27.3%), adrenal hemorrhage (n = 12; 27.3%), upper quadrant cyst (including 2 duplication cysts, 1 splenic cyst, and 3 indeterminate cysts), neuroblastoma (n = 4), adrenal hyperplasia (n = 3), bilateral adrenal calcifications (n = 1), and indeterminate lesions (n = 6). Sequestrations were uniformly left-sided (100 vs. 50%; p = 0.014) and diagnosed earlier in gestation than adrenal hemorrhages (p = 0.025). Sequestrations were also significantly more likely to have a prenatal feeding vessel (p = 0.005), low T1 MRI signal (p = 0.015), and no MRI blood products (p = 0.018) compared to adrenal hemorrhages. When comparing all 44 patients, a prenatal feeding vessel and low T1 signal on prenatal MRI were significantly associated with lesion persistence (p = 0.003; p = 0.044).

DISCUSSION/CONCLUSION

Imaging findings on prenatal ultrasound and MRI aid in the diagnosis of suprarenal lesions, including differentiating pulmonary sequestrations and adrenal hemorrhages.

Bilateral adrenal hemorrhage after colectomy for perforated diverticulitis: A case report

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Bilateral adrenal hemorrhage is a rare complication associated with major insult, associated with sepsis and coagulopathy.

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Postoperative bilateral adrenal hemorrhage could be lifethreatening and its essential to have high level of suspicion.

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The diagnosis for bilateral adrenal hemorrhage is based on biochemical testing and cross-sectional imaging.

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Treatment is with steroid replacement which could be temporary or permanent.

Introduction

Bilateral adrenal hemorrhage can lead to acute adrenal insufficiency. This is a rare complication in the post-operative setting, and we present a case in which it developed after a colectomy for perforated diverticulitis.

Presentation of case

The patient is a 65-year-old female who presented with abdominal pain, nausea, emesis, and hematochezia, and CT scan showing sigmoid diverticulitis with peri-sigmoid abscess. After a failure of non-operative treatment, she underwent Hartmann’s resection, and her post-operative course was complicated by refractory tachycardia, hypotension, hyponatremia, and nausea/vomiting. Bleeding, hypovolemia, and sepsis were ruled out. A CT scan showed enlarged poorly defined adrenals bilaterally, suggestive of bilateral adrenal hemorrhage. Serum cortisol level was low and diagnostic of acute adrenal insufficiency. With intravenous steroid therapy (hydrocortisone), her vital signs, laboratory abnormalities, and diet intolerance all resolved. She was discharged on oral prednisone and continued long term.

Discussion

Bilateral adrenal hemorrhage is rare post-operatively and can lead to adrenal insufficiency. 15% of patients who die in shock have bilateral adrenal hemorrhage on autopsy, indicating the necessity of timely diagnosis and treatment of this condition. Corticosteroid therapy is the mainstay of treatment.

Conclusion

This case study illustrates that post-operative delay of progression or worsening of condition, with no alternative explanation, can be due to acute adrenal insufficiency resulting from bilateral adrenal hemorrhage, and timely diagnosis and treatment of this condition is paramount for a favorable outcome.

Adrenal hematoma following falling in a 5-year-old boy

There is scarcity of reports regarding adrenal hemorrhage secondary to blunt abdominal trauma, which is as a result of the location of the adrenal glands. Most adrenal injuries occur in the right gland solitary and they are not life-threatening. Hence, they can be treated with conservative actions. In this case report, we describe the history a 5-year-old child with the history of falling and was diagnosed with adrenal hemorrhage. He did not need any surgical procedures and the outcome of conservative treatment was satisfactory.

Idiopathic unilateral adrenal hemorrhage in a term pregnant primigravida female

Idiopathic or spontaneous adrenal hemorrhage is a rare entity and a serious medical condition which is usually underestimated but can result in multiorgan failure, hemodynamic instability and death. It is usually diagnosed postmortem, as it has a nonspecific presentation in view of some other concurrent illness. Pregnancy-induced adrenal hemorrhage in itself is quite rare and a poorly understood disorder. We report here a case of 24-year-old primigravida female at 38 + 6 weeks of gestation who presented with right loin pain associated with fever and chills. Abdominal ultrasound and magnetic resonance imaging were performed which revealed presence of hematoma in right suprarenal location. A diagnosis of idiopathic right adrenal hemorrhage was made. The patient was managed conservatively and was stable post delivery. As this condition can have complications which can potentially be life-threatening, clinicians should keep a high suspicion for this disease when a pregnant female presents with acute abdominal pain.

Resected case of stage IV pleomorphic carcinoma of the lung with long-term survival

Background

No established treatments for pulmonary pleomorphic carcinoma exist because of its rarity, and the prognosis is poorer than that of other non-small cell lung cancers.

Case report

We present a case of stage IV pleomorphic carcinoma; the patient was a 66-year-old male. He was referred to our hospital because of a right adrenal hemorrhage and a lung tumor. A systemic examination revealed that the lung tumor was a primary lung cancer and that the adrenal hemorrhage was due to a metastatic cancer. We performed an adrenalectomy and resection of the lung tumor and obtained a diagnosis of pleomorphic carcinoma with adrenal metastasis. The patient has remained recurrence-free for 6 years since the surgery.

Conclusions

We report a patient with stage IV pleomorphic carcinoma of the lung and an oligometastasis in whom a complete resection enabled a good outcome. Additional reports are needed to clarify definite prognostic factors and the optimal treatment for pleomorphic carcinoma.

Spontaneous hemorrhage of an adrenal myelolipoma treated with transarterial embolization: A case report

Adrenal myelolipoma is a benign tumor of the adrenal cortex composed predominantly of fat and hematopoietic tissue. These lesions are usually asymptomatic, and most often incidentally detected on imaging. Uncommonly, they present with retroperitoneal hemorrhage, and these have been traditionally treated with emergent surgery. Although, transarterial embolization has been effectively and safely used in patients presenting with active hemorrhage from acute traumatic and nontraumatic causes, literature specifically pertaining to adrenal artery embolization is scant, perhaps due to smaller size and variability of adrenal arteries. With recent advances in endovascular techniques and imaging, there are emerging case reports and series of adrenal artery embolization in acute and nonacute settings. We report a case of spontaneous hemorrhage within an adrenal myelolipoma in a 43-year-old male patient, successfully treated with transarterial embolization, thereby avoiding major surgery. Our report adds to the growing body of literature pertaining to adrenal artery embolization.

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.

[Bilateral adrenal hemorrhage under apixaban in primary antiphospholipid syndrome]

INTRODUCTION

Adrenal hemorrhage is a classical but rare complication of antiphospholipid syndrome, revealing diagnosis in one third of the cases. Anti-vitamin K therapy is the standard treatment but direct oral anticoagulants are discussed as an alternative. In the latest recommendations, it is advised not to use direct oral anticoagulants in the setting of antiphospholipid syndrome.

CASE REPORT

We present a case of bilateral adrenal hemorrhage revealing primary antiphospholipid syndrome with triple positive antibody profile, in a 47-year-old man treated by apixaban for previous venous thromboembolism.

CONCLUSION

To our knowledge, it is the first case of adrenal hemorrhage occurring during apixaban treatment in a patient with antiphospholipid syndrome. This case illustrates the inefficacy of direct oral anticoagulants to prevent thrombotic events in antiphospholipid syndrome, in accordance with the latest recommendations.

Scrotal hematoma of the newborn in the tropics: What attitude?

Scrotal hematoma (SH) in newborn is a rare condition. It can occur secondary to adrenal hemorrhage which often is associated with birth trauma. Scrotal hematoma often raises the suspicion of testicular torsion leading to unnecessary surgery. We report two cases which improved our management approach.

Bilateral adrenal hemorrhage revealed antiphospholipid syndrome in a male patient: benefit from comprehensive treatment

BACKGROUND

Adrenal hemorrhage caused by antiphospholipid syndrome (APS) secondary to systemic lupus erythematosus (SLE) is very rare, especially in males.

REPORT

This study reports a 45-year-old male patient who presented with fatigue, loss of appetite, nausea, and vomiting for 2 months with a history of recurring epilepsy. On examination, he had low blood pressure (95/53 mmHg) and hyponatremia (117.9 mmol/L). His abdominal computed tomography (CT) scan showed bilateral diffusely enlarged adrenal hemorrhage. Laboratory studies revealed evidence of APS secondary to SLE. He remains well with adrenal lesions shrunken under the treatment of steroid, cyclophosphamide, hydroxychloroquine, warfarin, oxcarbazepine and entecavir.

CONCLUSION

This case is presented as a warning that the correct diagnosis of adrenal hemorrhage and appropriate treatment is needed, especially when complications set in.

Bilateral adrenal hemorrhage in a neonatal kidney donor

EKT from neonatal donors remains rare despite successful outcome being reported. The surgical aspects of neonatal abdominal organ recovery remain unfamiliar to the vast majority of abdominal organ recovery teams and renal transplant surgeons. BAH is not uncommon in newborn babies suffering distress in the perinatal period. BAH is often also associated with RVT and will impact on utilization of kidneys for transplantation. We present a case of a neonatal kidney donor with massive BAHs discovered at the time of organ recovery. This made the procurement challenging. Both kidneys were recovered en bloc with pancreas and the liver with aorta and inferior vena cave as vascular conduits. The kidneys were successfully implanted into an adult recipient with good function at 1-year follow-up. Association between adrenal hemorrhage and RVT needs to be considered before utilizing such kidneys. This case exemplifies successful outcome after careful assessment and transplantation of such kidneys.

Persistent Primary Aldosteronism Despite Iatrogenic Adrenal Hemorrhage After Adrenal Vein Sampling

Before surgery for primary aldosteronism (PA), localization is evaluated with adrenal vein sampling (AVS). A 56-year-old Japanese woman had a right adrenal mass, hypokalemia, and a high aldosterone/renin ratio. Stress tests confirmed the diagnosis of PA. Subsequently, preoperative AVS was performed and right adrenal hemorrhage (AH) occurred unexpectedly. Because hypertension persisted, laparoscopic right adrenalectomy was performed. Postoperatively, the blood pressure was normalized. Pathological examination revealed an adrenal cortical adenoma largely unaffected by necrosis and hemorrhage. Previous reports have also indicated that AH may not ameliorate PA. We discussed the clinical progress of AH and the measures to prevent causing AH.

Neonatal adrenal hemorrhage presenting as "Acute Scrotum"-looking beyond the obvious: a sonographic insight

Acute swelling and discoloration of scrotum in new born can have many localized causes like testicular torsion, inguinal hernia, scrotal or testicular edema, hydrocele, or even remote causes like adrenal hemorrhage. We report a neonate of adrenal hemorrhage presenting clinically as acute scrotum misguiding the clinician to rule out a local scrotal pathology. As the local clinical examination is not reliable in a newborn, it definitely requires an imaging evaluation to establish the diagnosis. This case report emphasizes being aware of the clinical association of acute adrenal hemorrhage and an acute scrotum and the role of ultrasonography in the evaluation of the various differential diagnoses leading to an acute scrotum. An optimum sonographic examination helps in suspecting an abdominal pathology as a cause of acute scrotum and in establishing the specific diagnosis of adrenal hemorrhage to avoid an unnecessary surgical exploration.

Nontraumatic adrenal hemorrhage: the adrenal stress

Bilateral adrenal hemorrhage is a rare condition, which is burdened by potentially life-threatening consequences related to the development of acute adrenal insufficiency. Despite treatment with stress-dose glucocorticoids, a mortality rate of 15% has been reported, which varies according to the severity of underlying predisposing illness and could be much more higher if the adrenal insufficiency is not promptly recognized. An early diagnosis is crucial, though, because of nonspecific clinical and laboratory findings, adrenal hemorrhage is rarely suspected. Therefore, imaging has a pivotal role for the diagnosis of this uncommon condition but, despite adrenal hematomas characteristically appear round or oval with peripheral fat stranding, their initial presentation could be ambiguous. The authors describe a case of postoperative bilateral adrenal hemorrhage initially presenting at computed tomography scan as thickening of both glands surrounded by fat stranding, which led to close monitoring of adrenal function before unequivocal hemorrhage developed.

Sonographic Diagnosis of Fetal Adrenal Hemorrhage Complicating a Vein of Galen Aneurysmal Malformation

BACKGROUND

The vein of Galen aneurysmal malformation (VGAM) is a rare intracranial vascular malformation which causes end-organ ischemia or venous congestion due to heart failure. Adrenal hemorrhage associated with VGAM has not been reported in the literature. We present the imaging findings of a fetal VGAM with adrenal hemorrhage.

CASE REPORT

A 26 year-old primigravida woman whose fetus with VGAM and mild cardiomegaly was scanned in the 34th week. On fetal ultrasound, a hyperechoic, well-circumscribed mass in the left suprarenal region was shown. Fetal and postnatal magnetic resonance imaging confirmed the diagnosis of adrenal hemorrhage. The baby died after delivery.

CONCLUSION

Adrenal hemorrhage can complicate VGAM in fetuses with severe heart failure. Evaluation of the adrenal gland in affected cases may contribute to the prenatal counseling, and postnatal management.

Adrenal congestion preceding adrenal hemorrhage on CT imaging: a case series

INTRODUCTION

Adrenal hemorrhage is an uncommon but potentially life-threatening condition, particularly in cases of bilateral adrenal hemorrhage causing primary adrenal insufficiency. It is difficult to diagnose clinically, particularly in critically ill patients, given its non-specific symptoms and signs, which include abdominal pain, vomiting, fever, weakness, hypotension, and altered conscious state. Non-traumatic adrenal hemorrhage has been observed to occur in times of physiological stress, such as post-surgery, sepsis, burns, and hypotension. This is hypothesized to be due to a combination of increased arterial blood flow to the adrenal glands, the paucity of draining adrenal venules and adrenal vein thrombosis, leading to intra-glandular vascular congestion and subsequent hemorrhage.

CASE SERIES

We present four cases of non-traumatic adrenal hemorrhage, which demonstrated features of preceding adrenal congestion (adrenal gland thickening and peri-adrenal fat stranding) on computed tomography (CT) imaging. Comparison was made with 12 randomly selected intensive care patients to observe if these findings were prevalent in this subgroup of patients.

CONCLUSION

Non-traumatic adrenal hemorrhage is an uncommon condition that is difficult to diagnose clinically. As such, it may be useful to recognize CT features of adrenal congestion as a sign for potential adrenal dysfunction and subsequent adrenal hemorrhage, so early steroid replacement therapy can be commenced to prevent death from adrenal insufficiency.

Spontaneous heparin-induced thrombocytopenia presenting as bilateral adrenal hemorrhages and pulmonary embolism after total knee arthroplasty

Heparin-induced thrombocytopenia syndrome is an acquired potentially life-threatening prothrombotic disorder caused by antibodies that recognize complexes of platelet factor 4 bound to heparin or heparin-like molecules. It typically occurs after exposure to unfractionated heparin, to a lesser extent after exposure to low-molecular-weight heparins, and rarely after exposure to fondaparinux. Herein, we report the case of a 48-year-old woman who developed severe thrombocytopenia, bilateral pulmonary embolism, and bilateral adrenal hemorrhages after total knee arthroplasty without evidence of heparin exposure. Antibodies to the heparin-platelet factor 4 complex and serotonin-release assay were positive. Spontaneous heparin-induced thrombocytopenia syndrome should be considered in patients with unexplained thrombocytopenia after knee replacement surgery even without heparin exposure, and a high index of suspicion for adrenal hemorrhage is needed in patients with fever, abdominal pain, and shock.

Idiopathic adrenal hematoma masquerading as neoplasm

We report herein a case of idiopathic adrenal hematoma. A 59-year-old Japanese man was referred to our hospital for evaluation of a 7.0 cm mass in the right upper abdominal cavity. The tumor was suspected to originate from either the posterior segment of the liver or the right adrenal gland. His chief complaint was weight loss of 8 kg over the previous 6 months. He had no past medical history and took no medications, including no anticoagulants. Laboratory data were almost normal except for a slight elevation of PIVKA-II. The origin of the tumor was found to be the adrenal gland, as angiography revealed the blood supply to the mass to derive from the right superior and inferior adrenal arteries. A fine needle biopsy of the lesion was unable to confirm the diagnosis. Open right adrenalectomy was performed. The histopathological findings of the surgical specimen revealed a hematoma with normal adrenal tissue. In the absence of any obvious etiology, the diagnosis was idiopathic adrenal hematoma.

Comparison of clinico-radiological features between congenital cystic neuroblastoma and neonatal adrenal hemorrhagic pseudocyst

OBJECTIVE

To evaluate the radiological and clinical findings of congenital cystic neuroblastomas as compared with those of the cystic presentation of neonatal adrenal hemorrhage.

MATERIALS AND METHODS

We analyzed the US (n = 52), CT (n = 24), and MR (n = 4) images as well as the medical records of 28 patients harboring congenital cystic neuroblastomas (n = 16) and neonatal adrenal hemorrhagic pseudocysts (n = 14). The history of prenatal detection, location, size, presence of outer wall enhancement, internal septations, solid portion, calcification, turbidity, vascular flow on a Doppler examination, and evolution patterns were compared in two groups of cystic lesions, by Fischer's exact test.

RESULTS

All (100%) neuroblastomas and three (21%) of the 14 hemorrhagic pseudocysts were detected prenatally. Both groups of cystic lesions occurred more frequently on the right side; 11 of 16 (69%) for neuroblastomas and 11 of 14 (79%) for hemorrhagic pseudocysts. The size, presence of solid portion, septum, enhancement, and turbidity did not differ significantly (p > 0.05) between the two groups of cystic lesions. However, tiny calcifications (n = 3) and vascular flow on color Doppler US (n = 3) were noted in only neuroblastomas. The cystic neuroblastomas became complex solid and cystic masses, and did not disappear for up to 90 days in the three following cases, whereas 11 of the 14 (79%) hemorrhagic pseudocysts disappeared completely and the three remaining (27%) evolved to calcifications only.

CONCLUSION

Although the imaging findings of two groups of cystic lesions were similar, prenatal detection, the presence of calcification on initial images, vascularity on color Doppler US, and evolution to a more complex mass may all favor neuroblastomas.

Spontaneous adrenal hemorrhage during pregnancy: review of literature and case report of successful conservative management

Spontaneous adrenal hemorrhage is an acute hemorrhage from the adrenal gland which occurs in the absence of trauma. The incidence of this condition during pregnancy is unknown. We describe a patient with massive unilateral adrenal hemorrhage which occurred during labor. The patient was successfully managed conservatively with complete resolution of the hematoma. A review of the literature of this rare condition is also presented.