Spontaneous Adrenal Hemorrhage Research Articles

Spontaneous Adrenal Hemorrhage in Pregnancy

Spontaneous Adrenal Hemorrhage in Pregnancy

Spontaneous adrenal hematoma in pregnancy: A case report

Abdominal pain is a very common complaint during pregnancy, which can be because of a number of causes including surgical, non-surgical and pregnancy related factors. A rare cause of abdominal pain is adrenal haemorrhage, which can be traumatic as well as spontaneous. The exact incidence of spontaneous adrenal haemorrhage in pregnancy is not known, however various autopsy series have shown it to be 0.3-1.8% in general population. We present a case report of 27 year female with pain abdomen. On further evaluation, she was found to have left adrenal lesion for which she underwent left sided adrenalectomy. Common causes of adrenal haemorrhage include trauma, stress like surgery, sepsis, burns, pregnancy, anticoagulation or coagulopathy. Spontaneous adrenal haemorrhage is a rare diagnosis in pregnancy and a high degree of suspicion is needed for diagnosis. A preoperative diagnosis of adrenal hematoma is difficult to make and is usually made postoperatively.

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.

FRI240 Aspirin Induced Adrenal Hemorrhage: Rare Side Effect Of A Common Medication!

Abstract Disclosure: H.A. Qadeer: None. R. Samkutty: None. V. Singh: None. Introduction: Adrenal hemorrhage is a heterogeneous disorder with various clinical presentations. Bilateral adrenal hemorrhage can result in acute adrenal insufficiency that can be fatal. With the increasing use of DOAC, cases of anticoagulation therapy induced adrenal hemorrhage have been reported. We present a rare case of unilateral adrenal hemorrhage in a patient with pre-existing adrenal myelolipoma after using Aspirin. Based on our literature search, previously only two cases of Aspirin Induced adrenal hemorrhage in a stable adrenal mass have been reported. Case Presentation: 55-year-old male with history of stable 6.2 cm right adrenal gland myelolipoma, fatty liver disease and hypertension, recent use of 2 doses 81 mg Aspirin after receiving right shoulder replacement surgery presented to emergency department with acute onset right sided flank pain, constant, radiating to the back and right upper quadrant associated with an episode of vomiting. He was hemodynamically stable. Blood work showed normal electrolytes, liver function and renal function at baseline. Hemoglobin was stable around 10g/dL. CT scan abdomen/pelvis with contrast showed increase in the size of a previously stable adrenal myelolipoma to 12.9 x 15.6 cm with mass effect upon the liver. Acute hemorrhage was suspected with the blood extending beyond the margins of the mass into the right retroperitoneal space, displacing the right kidney. On admission, aspirin was discontinued. With absence of hemodynamic instability, normal electrolytes, and normal AM cortisol level of 11.9 mcg/dL, adrenal insufficiency was ruled out. Hormonal work up for hyperfunctioning adrenal tumor was performed that ruled out pheochromocytoma, Cushing syndrome and Primary Aldosteronism. With symptomatic improvement, absence of progression of adrenal hemorrhage on repeat CT scan of the abdomen/pelvis, patient was discharged home. He received IR guided embolization of the right superior adrenal artery and middle adrenal artery in the outpatient setting. Discussion: Spontaneous adrenal gland hemorrhage is a rare event. Bilateral adrenal hemorrhage is associated with acute adrenal insufficiency that can be fatal. Major risk factors for adrenal hemorrhage include anticoagulant therapy, heparin Induced thrombocytopenia, hypercoagulable state, trauma and sever sepsis. Here we have reported a rare case of adrenal gland hemorrhage with therapeutic dose of aspirin used after orthopedic surgery. Aspirin is a very commonly used medication and high index of suspicion is required to avoid this side effect as Immediate discontinuation of the medication is necessary to prevent progression of the disease. Conclusion: Aspirin use can be associated with progression of stable benign adrenal tumors by causing spontaneous hemorrhage. A high index of clinical suspicion is required for timely recognition of this side effect. Presentation: Friday, June 16, 2023

FRI229 Bilateral Adrenal Hemorrhage Following Deep Tissue Body Massage

Abstract Disclosure: M. Antony: None. S. Gundlapally: None. P. Russell: None. S. Storm: None. S. Patel: None. V. Verma: None. R. Kant: None. Introduction: Adrenal hemorrhages have been reported in patients undergoing ACTH stimulation test using bovine- source ACTH. It can also be seen in severe stressful situations such as septicemia and extensive thermal burns due to sudden and profound adrenocortical stimulation by endogenous ACTH. Idiopathic spontaneous adrenal hemorrhage and motor vehicle accident induced adrenal hemorrhage have also been rarely reported. Coagulopathy, thromboembolic disease, and postoperative state are 3 major risk factors associated with bilateral adrenal hemorrhage. We present a unique case of a patient who presented with bilateral adrenal hemorrhage following deep tissue body massage. Clinical Case: A 44-year-old male with a past medical history of recurrent pulmonary embolism (PE) and deep venous thrombosis (DVT) due to lupus anticoagulant disorder status-post inferior vena cava (IVC) filter and recent change from Coumadin to Xarelto presented to the ED with a chief complaint of right upper quadrant (RUQ) pain extending to the right flank. Patient experienced unrelenting pain after a deep-tissue massage one week prior to presentation. Patient was seen two days prior to admission for similar complaints, but was discharged after reassuring CT abdomen/pelvis, ultrasound, and labs. He returned after pain worsened, and a repeat CT showed right adrenal hemorrhage and enlargement. Patient denied all other symptoms except pain. Vitals included BP of 144/84 mmhg, RR 20/min, HR 89/min, temp of 98.1°F, and SpO2 of 99%. Physical exam was notable only for RUQ pain and right CVA tenderness. Initial labs showed normal CBC including HGB 13.6g/dL (13-17 g/dL), HCT 37.5% (38.5-52%), and PLT 181K/microL (150-450 K/microL). Glucose 120mg/dL (70-99mg/dL), Na 129mmol/L (135-146 mmol/L), K 3.3mmol/L (3.5-5.2 mmol/L), Cl 87mmol/L (98-107 mmol/L), anion gap 17mmol/L (4-15mmol/L). LFT, serum lipase and CPK were non-contributory. PT was elevated at 24.7s (10-13s) and INR was 2.1 (0.9-1.2). Anticoagulation was stopped for three to four weeks, and nonsurgical management was recommended. Potassium supplementation was given, and the patient was continued on his hypertension medications. On further investigation, origin of the hemorrhage was determined to be traumatic secondary to the massage during which the masseuse walked on the patient. The patient was discharged after three days but was readmitted after continued abdominal pain and hyponatremia. He was diagnosed with a left-sided adrenal hemorrhage on repeat CT scan twelve days after identification of the first. Medical management was successful. Conclusion: Adrenal hemorrhage is a potentially life-threatening condition often caused by trauma, severe burns, or septicemia. Anticoagulant therapy and thromboembolic disease, as seen in our patient, are also risk factors. The atypical trauma induced by the patient's massage likely initiated the hemorrhagic event. Presentation: Friday, June 16, 2023

PSAT029 Acute Presentations of 4 Patients with Spontaneous Adrenal Hemorrhage

Abstract Case 1 A 19 year old primigravida, 35 weeks gestation, presented with acute severe right flank pain and vomiting. She underwent a MR cholangiopancreatography following advice from the gastroenterologists. This revealed a right adrenal gland haemorrhage 46×24×40 mm. CRP was raised at 151mg/l. Random cortisol, potassium and plasma metanephrines (pMET) were normal. She was delivered by Caesarian Section at term with 100 mg IV hydrocortisone cover and with no complications to either mother or baby. CT adrenals performed 8 weeks postpartum was entirely normal with no evidence of residual haemorrhage or adrenal mass. Case 2 A 63 man with hypertension presented with acute severe left flank pain. CT renal and CT angiogram showed a large left adrenal and perinephric haemorrhage. This was treated with coil embolization of the left suprarenal artery. Initial biochemistry showed mildly raised plasma normetanephines at 2211 pmol/l which subsequently normalised. Overnight dexamethasone suppression test (ONDST) and aldosterone/plasma renin activity were normal. Serial CT scan showed gradual resolution of the adrenal haemorrhage with no underlying adrenal lesion. Case 3 A 56 year old man presented with a 3 day history of epigastric and left sided abdominal pain with nausea and fever. CT scan of the abdomen revealed a 5 cm adrenal haemorrhage which was contained within the gland. ONDST, pMET and aldosterone/plasma renin activity were normal. Serial scans showed resolution of the adrenal haemorrhage and a residual 14×13 mm adrenal nodule with a density of 20 Hounsfield Units but which remained unchanged in size. Case 4 A 72 year old man with generalised abdominal pain a week after hip replacement surgery. He developed a fever and his inflammatory markers were raised. CT abdomen showed non-enhancing bilateral adrenal lesions consistent with adrenal haemorrhage. He was taking Apixaban for thromboprophylaxis following hip replacement. A short synacthen test performed to rule out adrenal insufficiency showed a suboptimal cortisol response and treatment with hydrocortisone was commenced. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

PSAT045 Spontaneous Adrenal Hemorrhage with Partial Adrenal Insufficiency in a Patient Anticoagulated with Apixaban for Antiphospholipid Syndrome

Abstract Background Addison's disease secondary to adrenal hemorrhage is a rare complication of antiphospholipid syndrome (APLS). Anticoagulation with a direct oral anticoagulant (DOAC) might increase the risk of adrenal hemorrhage. We report a patient who developed bilateral adrenal hemorrhage after starting apixaban for deep venous thrombosis (DVT) and pulmonary embolism (PE) in the setting of latent APLS. Clinical Case A 45-year-old man without significant past medical history presented with a left lower extremity DVT and PE. He had no personal or family history of previous trauma, bleeding or clotting events. He was discharged on apixaban. Three days later he was readmitted with bilateral flank pain. Computerized tomography (CT) imaging showed bilateral adrenal gland edema. He was hemodynamically stable. Due to persistent right flank pain and concern for ileus, CT was repeated and revealed findings concerning for adrenal hemorrhage. He subsequently complained of asthenia. Further testing revealed a reduced morning cortisol of 1.4 ug/dL (reference: 6.0 - 18.4 ug/dL) and an elevated morning ACTH of 149 pg/mL (7.2-63.3 pg/mL). Plasma dehydroepiandrosterone sulphate (DHEA-S) was reduced at 39 mcg/dL (70 - 495 mcg/dL), and epinephrine and norepinephrine were undetectable. Morning plasma aldosterone was undetectable and renin activity was 0.76 ng/mL/h (0.25 - 5.82 ng/mL/h). He was started on stress dose steroids and discharged on maintenance hydrocortisone without reinitiating anticoagulation. Two weeks later, he re-presented with a right lower extremity DVT. An APLS panel revealed elevated anti-beta2 glycoprotein 1 IgG and anti-cardiolipin IgG. Laboratory work-up for other causes of thrombosis, including inherited and acquired thrombophilias, anatomical vascular obstruction, paroxysmal nocturnal hemoglobinuria (PNH), heparin-induced thrombocytopenia (HIT), and myeloproliferative neoplasms (MPN), was unrevealing. Warfarin was started with an international normalized ratio (INR) target range of 2-3. Hydrocortisone was continued at a total daily dose of 30mg. Since discharge, his morning cortisol levels have been low at 4.4-4.9 ug/dL and ACTH has remained high at 92-137 pg/mL, but aldosterone has been variable at <1 to 9 ng/dL, and renin has been normal at 0.35 ng/mL/h. This suggests what transpired had been microthrombi-associated intra-adrenal hemorrhage involving the zona fasciculata with sparing of the glomerulosa. Conclusion This case highlights DOAC-associated adrenal hemorrhage in a patient with underlying APLS, an under-appreciated complication. The extent to which the various layers of the adrenal gland are affected may vary. Since guidelines on the management of patients with partial adrenal insufficiency are lacking, further reporting is needed on long term outcomes and adrenal function of these patients. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Acute Adrenal Hemorrhage as the Initial Manifestation of Metastatic Lung Adenocarcinoma: A Cautionary Tale

Adrenal gland metastatic disease is the most commonly occurring malignancy of the adrenal glands. Although metastatic disease is common, adrenal hemorrhage is a rare but potentially fatal manifestation of malignancy. The objectives of this case report are to highlight the unusual presentation of metastatic lung adenocarcinoma as spontaneous adrenal hemorrhage in a 64-year-old female who was otherwise asymptomatic. As well as to support the reasoning that metastatic disease should be considered as a differential in patients with this clinical presentation as this may have altered this fatal outcome.

Unilateral Spontaneous Adrenal Haemorrhage in Pregnancy

Spontaneous Adrenal Haemorrhage (SAH) is a rare condition in which there is haemorrhage in the adrenal gland without any adrenal tumour or history of trauma. It presents as severe flank pain with or without shock depending on the amount of haemorrhage. The initial investigation of choice is ultrasound and the diagnosis can be confirmed by computed tomography or magnetic resonance imaging We report the case of a pregnant female, presenting with left flank pain and high blood pressure, in the late third trimester. Ultrasonography revealed intra-uterine fetal demise with a large left suprarenal mass. Subsequent imaging by computed tomography and magnetic resonance imaging revealed a heterogeneous left adrenal mass with imaging features suggestive of haemorrhage. The patient delivered spontaneously and her blood pressure returned to normal spontaneously. She was explained about the entity as well as the risks and benefits of surgery for this condition. She did not want to undergo surgery and decided to be on regular follow-up. We repeated the ultrasound every 2 weeks, which showed no increase in the size of the lesion. The patient was asked to continue monthly follow-up for 3 months followed by 3-monthly follow-up by ultrasonography. This case reiterates the fact that obstetricians should keep a highindex of suspicion for this rare condition after ruling out more common causes of flank pain in pregnancy, and should suspect SAH especially if there is associated severe anemia or shock. The knowledge of this rare entity can help in correct diagnosis and early appropriate treatment.

Acute presentations of 4 patients with spontaneous adrenal haemorrhage

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Spontaneous Adrenal Haemorrhage in Early Twin Pregnancy: A Case Report of Successful Conservative Management

Spontaneous adrenal haemorrhage in pregnancy is an extremely rare condition. Herein we present an additional case of unilateral spontaneous adrenal haemorrhage in a 31-year-old pregnant woman at the 15 weeks of gestation with successful conservative management and a safe vaginal delivery.

Spontaneous adrenal haemorrhage and adrenal deficiency during third trimester - successful delivery with conservative management: A case report

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Unilateral left spontaneous adrenal haemorrhage in a middle aged male. A case report

BackgroundAdrenal haemorrhage is a rare condition, traditionally diagnosed at autopsy. Aetiology of adrenal haemorrhage can be traumatic or non-traumatic related. Rare cases of spontaneous adrenal haemorrhage, mostly from the right adrenal gland have been documented without any identifiable predisposing aetiologies. Case presentationA middle aged male with no comorbidities presented to the emergency department with non-specific signs and symptoms. There was no history of trauma and the haemoglobin was dropping. Initial investigations showed abdominal haematomas with no clear source. Taken to theatre, a diagnosis of a left spontaneous adrenal haemorrhage was made and left adrenalectomy was performed. ConclusionAdrenal haemorrhage is associated with severe complications such as adrenal insufficiency, sepsis and death. The following report will explore one such case, of a patient diagnosed with spontaneous left adrenal haemorrhage that was complicated by sepsis and death.

Spontaneous Bilateral Adrenal Hemorrhage in Pregnancy

Introduction: Spontaneous Adrenal Hemorrhage (SAH) in pregnancy is a rare occurrence with estimated prevalence of 0.03% to 1.8%. SAH usually involves the right gland and can be easily mistaken with other conditions due to its nonspecific symptoms. We hereby report 2 cases of spontaneous bilateral SAH that occurred during the 3rd trimester of pregnancy. Case 1: 28-year-old female with history of IBS presented during 35th week of her first pregnancy with right-sided abdominal pain. Abdominal MRI revealed a 4.7 x 2.8 cm right adrenal hemorrhage. Due to stability of her vitals, steroids were not initiated and she was discharged. She returned 4 days later with similar pain but this time on the left side. MRI did not reveal adrenal bleeding. Due to Blood Pressure (BP) of 90/70 mmHg, hydrocortisone IV 50mg every 8 hours was started. 36 hour later she became tachycardic and tachypneic. CT angiogram (CTa) ruled out Pulmonary Emboli (PE), but was remarkable for interval development of a 5.3 x 3 cm left adrenal hemorrhage. There were no findings indicative of Primary Adrenal Insufficiency (PAI). Patient was discharged home on physiologic dose of hydrocortisone and delivered a healthy baby 2 weeks later at term. Case 2: 30-year-old female with history of hypertension and polycystic kidney disease presented at 31st week of her 2nd pregnancy with left-sided abdominal pain. Abdominal CT scan showed a 2.3 x 3.1 cm left adrenal hemorrhage. Due to BP of 85/50 mmHg at presentation, she was started on hydrocortisone IV 50 mg one dose followed by 25 mg every 8 hours, which improved her BP. 3 days later she developed new right flank pain. MRI was remarkable for features indicative of adrenal hyperplasia but did not confirm presence of hemorrhage. 1 day later she developed hypoxia and underwent CTa to rule out PE, which was remarkable for a new right adrenal hemorrhage. She did not have findings indicative of PAI and was discharged home on physiologic dose of hydrocortisone. Unfortunately, the pregnancy resulted in intrauterine fetal death at 36 weeks. Discussion: Adrenal cortex hyperplasia secondary to physiological elevation of ACTH plus adrenal venous constriction due to increased catecholamine release, have been suggested as possible mechanisms for increased risk of SAH in pregnancy. Common manifestations of SAH include abdominal pain, fever, fatigue, dizziness, anemia and hypotension. Features of PAI such as hyponatremia and hyperkalemia should be expected in cases of over 90% damage of adrenal cortices. Management in pregnancy involves fluid resuscitation, close monitoring for findings suggestive of adrenal crisis, fetal monitoring and glucocorticoid +/- mineralocorticoid replacement if indicated. Possibility for development of bilateral SAH should always be considered in patients who develop unilateral SAH. If left unrecognized, SAH is associated with poor outcomes and high fatality rate for both mother and fetus.

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.

Acute adrenal insufficiency secondary to spontaneous bilateral adrenal haemorrhage following salvage cystectomy

Acute adrenal insufficiency secondary to spontaneous bilateral adrenal haemorrhage following salvage cystectomy

Adrenal Cystic Lesion Presented With Spontaneous Hemorrhage

Adrenal hemorrhage is a rare but life-threatening condition. Spontaneous hemorrhage occurs without any trauma. A focal bleeding may cause even a subclinical condition or cardiovascular collapse with massive bleeding. Non-proper diagnosis may cause even death. In literature most of the cases are treated conservatively. Conservative treatment necessitates close follow up and if fails, surgery becomes challenging. Here, we present a case with spontaneous adrenal hemorrhage that was first taken to conservative treatment and undergone emergency surgery.

SUN-192 Spontaneous Adrenal Hemorrhage in a Patient with Antiphospholipid Syndrome on Rivaroxaban: A Potentially Fatal Complication

Introduction: Primary Adrenal insufficiency is an uncommon complication of antiphospholipid syndrome, with an incidence of 0.4% [2]. It is often secondary to bilateral adrenal hemorrhage. We present a case of bilateral adrenal hemorrhage in a patient with APLS on anticoagulation with rivaroxaban. Case: 46-year-old m with a history of antiphospholipid syndrome, recently transitioned from warfarin to rivaroxaban for anticoagulation, who presented to the ED after a syncopal episode following a prior episode of abdominal pain with an unremarkable work-up. He subsequently developed severe fatigue, dizziness, headaches, nausea and 15 lbs weight loss. On presentation, the patient was hypotensive(72/45 mmHg) and tachycardic. Intravenous hydration was started with minimal response. Initial laboratory testing showed serum sodium of 121mmol/L, potassium of 5.5mmol/L and random cortisol of 0.8mcg/dL. The patient was admitted to the intensive care unit where he was started on vasopressors and hydrocortisone 50 mg IV every 8 hours. A non-contrast CT of the abdomen and pelvis showed thickening of the adrenal glands with decreased attenuation. MRI of the abdomen showed hyper-intensity of the adrenal glands bilaterally (T1 images), without post-contrast enhancement suggestive of bilateral adrenal hemorrhage. His electrolytes normalized, and he was successfully discharged home on hydrocortisone and fludrocortisone replacement with outpatient follow-up. Discussion: Atraumatic bilateral adrenal hemorrhage is rare, but remains one of the most common endocrine-related complications of antiphospholipid syndrome (APLS). The venous anatomical configuration of the adrenal gland increases risk of thrombotic hemorrhagic infarction[1]. Patients with APLS are commonly anticoagulated to prevent thrombosis. The ideal anticoagulation regimen remains controversial. Only three other cases of spontaneous bilateral adrenal hemorrhage on patients with APLS using new oral anticoagulants (NOACs) were reported. The use of NOACs seem to increase the already-elevated risk of adrenal hemorrhage seen in patients with APLS.

SAT-182 Bilateral Adrenal Hemorrhage with Clinically Preserved Adrenal Function Leading to the Diagnosis of Antiphospholipid Syndrome

Background: Spontaneous bilateral adrenal hemorrhage (BAH) is a rare complication of antiphospholipid syndrome (APS), which is the most common identifiable risk factor for BAH. Although adrenal dysfunction is generally irreversible, adrenal function might be preserved or even recover in rare cases1.Clinical case: A 48 year-old man with history of hypertension and gout presented with right upper quadrant abdominal pain following trauma to his left leg. He was found to have a left lower extremity deep vein thrombosis and bilateral pulmonary emboli (PE) and was started on anticoagulation therapy. He continued to have abdominal pain and a CT abdomen revealed BAH. Three am cortisol level was 21 mcg/dL (8–25 mcg/dL), ACTH 37 pg/mL (6–59 pg/mL), aldosterone <3 ng/dL (4–31 ng/dL), renin 2.6 ng/mL/hr (0.2–1.6 ng/mL/hr), sodium 130 mmol/L (135–146 mmol/L) and potassium 4.3 mmol/L (3.6–5.3 mmol/L). Patient was hemodynamically stable and did not report symptoms of adrenal insufficiency. Hypercoagulable work-up was consistent with APS and Lupus. Despite normal cortisol levels, he was started on hydrocortisone in the setting of anticoagulation and recent hemorrhage. Given low aldosterone with slightly high renin he was also started on fludrocortisone. Six weeks after discharge, his morning cortisol was 6 mcg/dL and ACTH was elevated at 76 pg/mL which was concerning for adrenal insufficiency. However, 250 mcg IM ACTH stimulation test showed peak cortisol of 17 mcg/dL which is considered adequate. Aldosterone and renin levels normalized so fludrocortisone was discontinued.Patient subsequently self-discontinued all medications for 1 month with no symptoms of adrenal insufficiency, and later restarted hydrocortisone on his own. Repeat ACTH stimulation test showed baseline ACTH 57 pg/mL with peak cortisol of 17 mcg/dL. Patient was tapered off hydrocortisone and displayed no subsequent symptoms of adrenal insufficiency.Conclusion: This case highlights the need to consider APS in patients with spontaneous BAH. Additionally, patients with BAH may have relatively preserved adrenal function. There is limited data to guide when steroid replacement is necessary for patients without clear adrenal insufficiency. It may be reasonable to monitor these patients off hydrocortisone replacement with close monitoring.1. Ramon I, Mathian A, Bachelot A, et al. Primary adrenal insufficiency due to bilateral adrenal hemorrhage-adrenal infarction in the antiphospholipid syndrome: long-term outcome of 16 patients. J Clin Endocrinol Metab. 2013;98(8):3179–3189.

Spontaneous Adrenal Hemorrhage—a Mixed Bag: 18 Cases from a Single Institution

Spontaneous adrenal hemorrhage is a rare clinical entity which can lead to an adrenal crisis, shock, and death. We conducted this study to analyze the etiopathogenesis, clinical presentation, imaging modality, and treatment of patients with spontaneous adrenal hemorrhage. Retrospective analysis of 18 patients with spontaneous adrenal hemorrhage managed between 2005 and 2017 at a single institution was performed. The most common presenting symptom was abdominal pain in 10 (55.6%) patients. Contrast-enhanced computerized tomography (CECT) was the most commonly used diagnostic modality (16/18 [88%]). Bilateral adrenal hemorrhage was seen in 6 patients (33%). Adrenal insufficiency was detected in 7 (38.9%) and these patients received steroid therapy. Etiology of the bleed included idiopathic (5 [27.8%]), antiphospholipid antibody syndrome (APLA) (5 [27.8%]), and pheochromocytoma (4 [22.2%]), associated with pregnancy, anticoagulant use, pseudoaneurysm, and myelolipoma in 1 (5.5%) each. Nine (50%) patients could be managed conservatively, and 8 (44.4%) required adrenalectomy while embolization was performed in one (5.6%). There were no mortalities. In this series, the most common clinical presentation of a patient with spontaneous adrenal hemorrhage was abdominal pain. The detection of an unexplained adrenal hemorrhage should prompt one to look for predisposing conditions like APLA. Patients with adrenal hemorrhage should be evaluated for adrenal insufficiency and if present, steroid therapy needs to be initiated. As seen in this series, not all patients with adrenal hemorrhage require an adrenalectomy.