Unilateral Adrenal Hemorrhage Research Articles

12386 Unilateral Spontaneous Adrenal Hemorrhage In Pregnancy

Abstract Disclosure: A. Gondhi: None. M. Campana: None. M. Riofrio: None. J. Fazendin: None. D. Vodopivec: None. Unilateral Spontaneous Adrenal Hemorrhage In Pregnancy Introduction: Spontaneous adrenal hemorrhage (SAH) in pregnancy is a rare and under recognized entity with an incidence of 0.14% - 1.1%, mostly unilateral. We present a case of unilateral SAH managed with adrenalectomy during pregnancy. Case presentation: A 24-year-old 14-weeks pregnant woman was referred for right flank pain and nausea due to right adrenal lesion. Medical history significant for 4 first trimester miscarriages and family history of Breast cancer and Uterine cancer in mother, Pancreatic cancer in multiple family members on paternal side. She was hemodynamically stable. Abdominal-US showed right adrenal lesion. Non-contrast MRI abdomen showed a large collection in the right adrenal gland measuring 9.6cm x 9cm. Ability to assess for underlying lesion challenging given the amount of blood products and lack of IV contrast. Laboratory analysis showed an appropriately suppressed cortisol with 1 mg overnight dexamethasone suppression test (cortisol 1.3 mcg/dl, N<1.8 mcg/d Dexamethasone level 332 ng/dl, N<180-550 ng/dl), normal DHEA-S (135 mcg/dl, N=18-391mcg/dl), non-suppressed ACTH (18 pg/ml, N 7.2-63 pg/ml), normal aldosterone (8.1 ng/dl, N=3-39.2 ng/dl) with a non-suppressed renin (17.8 pg/ml, N=4.2-52.2 pg/ml), normal fractionated plasma metanephrines (Free metanephrines <0.2 nMol/L, N<0.0.5nMol/L Free normetaphrines <0.2 nMol/L, N<0.9nMol/L), negative Antiphopholipid antibody testing (Beta 2 Glycoprotein I IgM <2 U/ml, N<20U/ml, Beta 2 Glycoprotein I IgG 2.2 U/ml, N<20U/ml). The patient underwent a laparoscopic converted to open right adrenalectomy. Pathology showed a 9.6cm adrenal gland with organizing hematoma, vascular congestion, and hemorrhage. It also showed periadrenal adipose tissue with atypia, MDM2 gene amplification by FISH negative – ruling out liposarcoma. Post-operatively, her symptoms resolved without complications to the pregnancy. Differentials for adrenal hemorrhage in this pregnant patient include: 1) underlying adrenal tumor (most commonly pheochromocytoma), 2) coagulopathy (e.g. antiphospholipid syndrome), and 3) pregnancy-related adrenal hemorrhage (rare, mostly unilateral due to increased vascular flow to the adrenal gland and the hypercoagulability). After evaluating the adrenal functionality, APLAS and assessing the malignant potential with imaging studies; conservative management is appropriate in stable patients. Our patient underwent surgery due to recurrent intractable pain, and uncertainty regarding malignant potential of the adrenal mass given history of multiple cancers in the family. Conclusion: Our case highlights that when indicated, adrenalectomy in the II trimester is a safe and effective option in pregnancy. Individualized treatment should be chosen for each patient following shared decision-making. Presentation: 6/1/2024

Unilateral Adrenal Hemorrhage Accompanied by Subgaleal Hematoma with Severe Neonatal Anemia — Case Report

Unilateral Adrenal Hemorrhage Accompanied by Subgaleal Hematoma with Severe Neonatal Anemia — Case Report

Unilateral adrenal hemorrhage with variable adrenocortical dysfunction.

Unilateral adrenal hemorrhage with variable adrenocortical dysfunction.

Radiological Imaging Findings of Adrenal Abnormalities in TAFRO Syndrome: A Systematic Review.

This systematic review article aims to investigate the clinical and radiological imaging characteristics of adrenal abnormalities in patients with thrombocytopenia, anasarca, fever, reticulin fibrosis, renal dysfunction, and organomegaly (TAFRO) syndrome. We searched the literature in PubMed, the Cochrane Library, and the Web of Science Core Collection. Ultimately, we analyzed 11 studies with 22 patients plus our 1 patient, totaling 23 patients. The mean age was 47.0 ± 12.6 years. There were 20 male and 3 female patients, respectively. The histopathological analysis of lymph nodes was conducted in 15 patients (65.2%), and the diagnosis was consistent with TAFRO syndrome in all 15 patients. Among the 23 patients, 11 patients (18 adrenal glands) showed adrenal ischemia/infarction, 9 patients (13 adrenal glands) showed adrenal hemorrhage, and 4 patients (7 adrenal glands) showed adrenomegaly without evidence of concurrent ischemia/infarction or hemorrhage. One patient demonstrated unilateral adrenal hemorrhage and contralateral adrenomegaly. In patients with adrenal ischemia/infarction, the adrenal glands displayed poor enhancement through contrast-enhanced computed tomography (CT). In patients with adrenal hemorrhage, the adrenal glands revealed high attenuation through non-enhanced CT and hematoma through magnetic resonance imaging. Adrenomegaly, with or without adrenal ischemia/infarction or hemorrhage, was observed in all patients (23/23, 100%). The subsequent calcification of the affected adrenal glands was frequently observed (9/14, 64.3%) when a follow-up CT was performed. Abdominal pain was frequent (15/23, 65.2%), all of which occurred after the disease's onset, suggesting the importance of considering TAFRO syndrome as a cause of acute abdomen. Given the absence of evidence of adrenal abnormalities in non-TAFRO-idiopathic multicentric Castleman disease (iMCD), they may serve as diagnostic clues for differentiating TAFRO syndrome from non-TAFRO-iMCD.

FRI175 Presentation, Etiology And Outcomes Of Adrenal Hemorrhage A Large Single-center Study

Abstract Disclosure: M. Chinthapalli: None. P. Dogra: None. R. Sandooja: None. L. Rahimi: None. N.M. Iniguez Ariza: None. T. Foster: None. I. Bancos: None. Introduction: Adrenal glands are susceptible to hemorrhage due to their unique vasculature and physiological stress response. Scarce data are available on the presentation, etiology, and outcomes of adrenal hemorrhage (AH). Objective: To describe the presentation, etiological associations, and outcomes of patients with unilateral and bilateral AH. Methods: Single-center retrospective longitudinal study of consecutive patients reported to have AH on imaging performed between January 1st 2017-December 31st 2021. Clinical, baseline and follow up imaging, and laboratory data were reviewed. Subgroup analysis was performed based on the laterality (unilateral vs. bilateral) of AH. Results: Of 454 patients with AH (median age 62 years (IQR 50-70), 160 (35%) women), 383 (85%) had unilateral AH, 60 (13%) presented with synchronous bilateral AH, and 9 (2%) had unilateral AH followed by contralateral AH at a later time (metachronous bilateral AH). Only 93 (20%) patients had an evaluation by an endocrinologist. AH was discovered incidentally in 190 (42%) patients, and during evaluation for abdominal or back pain in 133 (29%), trauma in 104 (23%), sepsis in 19 (4%), and adrenal insufficiency in 8 (2%). Primary etiology of AH was a post-procedural complication in 154 (34%), trauma in 126 (28%), coagulopathy in 54 (12%), anticoagulant or antiplatelet therapy in 52 (12%), adrenal neoplasm in 29 (6%) and sepsis in 20 (4%). Metastasis (15, 50%) represented the most common adrenal neoplasm associated with AH. In 208 (46%) patients, diagnosis of AH occurred in the hospital setting, and in 246 (54%) during an outpatient evaluation. In the 393 patients with available baseline imaging, the median size of AH was 3.1 cm (IQR 2.2-4.0). During a median imaging follow-up of 6 months (IQR 3-12), AH reduced in size with a median decrease of -2.6 cm (IQR -1.8 to -3.7) on the right and -2.0 cm (IQR -1.0 to -4.8) on the left. Compared to patients with unilateral AH, those with bilateral AH were more likely to be diagnosed in the hospital setting (61 vs. 43%, P=0.006), have an underlying coagulopathy (50 vs. 4%, P<0.0001), or sepsis (13 vs. 3%, P<0.0001), be on anticoagulant or antiplatelet therapy (48 vs. 21%, P<0.0001), develop primary adrenal insufficiency (61 vs. 0%, P<0.0001) and have larger baseline AH size (4 cm vs. left 2.7 and right 3.1 cm, P=0.0002), but a similar rate of resolution. Conclusions: AH frequently presents as unilateral hemorrhage and can occur secondary to various etiologies, with trauma and postprocedural complication being the most common. Association with an underlying adrenal mass is uncommon, seen only in 6%. Bilateral AH carries a high risk for primary adrenal insufficiency and is more likely to occur in hospitalized patients, possibly due to an increased prevalence of underlying coagulopathy, sepsis and need for anticoagulation or antiplatelet therapy. Presentation: Friday, June 16, 2023

THU619 Atypical Clinical Presentation Of Adrenal Hemorrhage

Abstract Disclosure: T.L. Madsen-Barbosa: None. F.H. Antoni: None. A. Ghazi: None. Introduction: Adrenal hemorrhage (AH) is an uncommon condition that is challenging to diagnose due to its nonspecific findings. We illustrate a case of AH that presented with acute clinical deterioration and had catecholamine overproduction. Case: A 58-year-old woman with a history of migraine headaches and prediabetes presented to the emergency department for “the worst headache of her life” and palpitations of 4 hours duration. On admission, her blood pressure was 224/139 mmHg and heart rate was 102 bpm. Her physical examination was significant for diaphoresis and active vomiting. Initial laboratory tests showed hyperglycemia and leukocytosis. Her ECG, non-contrast CT scan of the head and CT angiography of the head and neck were unremarkable. Her hospital course was complicated by recurrent hypertensive episodes, arrhythmias including Torsades de pointes, and left flank pain. A CT chest, abdomen, and pelvis revealed a large left retroperitoneal hemorrhagic collection which seemed to arise from the inferior aspect of the left adrenal gland. She subsequently underwent successful IR embolization of the left inferior suprarenal artery. Further workup showed elevated urinary fractionated metanephrine and normetanephrine levels, as well as elevated levels of plasma free metanephrine and normetanephrine. Given concern for pheochromocytoma, phenoxybenzamine was started. A repeat CT abdomen after six days demonstrated shrinkage in hematoma and a 7 mm hypoattenuating nodule arising from the medial limb of the left adrenal gland. Outpatient follow-up CT abdomen showed left adrenal thickening with a 2.3 cm nodular area with 78.9 Hounsfield units and absolute washout of 60.9% suggestive of adenoma. After one month, repeat catecholamine levels normalized. Discussion: The clinical manifestation of AH varies widely. Acute adrenal insufficiency is seen if bilateral glands and 90% of the cortices are compromised. However, unilateral AH is most often asymptomatic - found incidentally on imaging. Having elevated catecholamines is described in 30% of patients in one case series. Differentiating spontaneous AH from hemorrhagic adrenal tumors is also a dilemma. Among the hemorrhagic adrenal masses, pheochromocytoma is the most common. Conclusion: This case highlights that clinicians should be aware of clinical manifestations of catecholamine excess when evaluating patients with AH. A catecholamine producing adrenal mass (pheochromocytoma) should also be ruled out in these situations. Reference:1- Elhassan YS, Ronchi C, Wijewickrama P, Balvedeweg SE. Approach to the patient with adrenal hemorrhage. J Clin Endocrinol Metab. 2023, 108 (4):995-1006.2- Karwacka IM, Obolonczyk L, Sworczak K. Adrenal hemorrhage: a single center experience and literature review. Adv Clin Exp Med. 2018; 27 (5): 681-687. Presentation: Thursday, June 15, 2023

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

Cardiopulmonary Arrest Due to Idiopathic Unilateral Adrenal Hemorrhage.

Cardiopulmonary Arrest Due to Idiopathic Unilateral Adrenal Hemorrhage.

LBODP015 A Pheochromocytoma Presenting With Hypertensive Emergency With A Rare Complication Of Unilateral Adrenal Hemorrhage

Abstract Introduction Adrenal hemorrhage is an uncommon finding in patients and is estimated to be present in 0.14-1.8% of postmortem examinations. Clinical diagnosis is challenging due to its non-specific presentation and most cases are diagnosed incidentally on imaging. Here we discuss the clinical presentation, diagnostic procedures, and outcome of this rare case. Clinical Case A 74-year-old Asian female presented to the ED with a sudden onset of severe epigastric pain with 9/10 intensity, radiating to her upper back while walking on the street. She was found in severe distress with a blood pressure of 214/80 mmHg, heart rate of 72 bpm, respiratory rate of 20 breaths/min, and oxygen saturation of 98% on room air. The physical exam was unremarkable. Laboratory findings were significant for elevated troponin of 1. 040 ng/ml (0. 00-0. 03 ng/ml), lactate 2.36mmol/L (0.70-2. 00 mmol/L), and lipase 481U/L (23-300 U/L). Chest X-ray was within normal limits. A CT angiogram of the chest and abdomen were negative for aortic dissection, however, a retroperitoneal hemorrhage measuring 6×8.5×6.5 cm was seen but an underlying adrenal gland mass could not be excluded. The patient was started on nitroglycerine drip for blood pressure control. Hemoglobin trend showed an acute drop, requiring 2 units of red blood cell transfusion. This raised concerns of worsening hemorrhage. Repeat imaging showed no significant change in the left adrenal hematoma, but arterial phase imaging still suggested active bleeding. Interventional radiology was consulted, and embolization of the left superior and inferior renal artery was done with stabilization of the patients hemodynamics. Laboratory work for secondary causes of hypertension was done. It showed elevated normetanephrines 1281 mcg/24hr (122 - 676 mcg/24hr) and total 24-hour urine metanephrines, 114 mcg/24hr (224-832 mcg/24 hr). The patients blood pressure was controlled and therefore asked for follow-up as an outpatient. Conclusion The majority of adrenal hemorrhages diagnosed are found incidentally, but initial symptoms of abdominal or loin pain are very important. Early acute findings may include tachycardia, hypotension, and severe abdominal pain. Subacute symptoms include flank tenderness, diarrhea, malaise, nausea, and vomiting. Unilateral adrenal hemorrhage may be the initial presentation of an underlying adrenal mass, cyst, coagulopathy or metastasis. Elevated cortisol and catecholamines released by an expanding hematoma are often seen along with elevated blood pressure, suggesting pheochromocytoma. The Hormonal analysis includes urine metanephrine and vanillylmandelic acid to rule out active pheochromocytoma. In our case, the patient had elevated urine metanephrines and normetanephrines suggestive of pheochromocytoma. Presentation: No date and time listed

PSAT038 A Case of Spontaneous Atraumatic Unilateral Adrenal Hemorrhage

Abstract Background Adrenal hemorrhage is a rare disorder with an incidence of 0.1 to 1% for which a cause is identified in most cases. It is usually classified as traumatic or atraumatic, unilateral or bilateral and can result in serious consequences such as adrenal crisis and death if not diagnosed and treated properly. We describe a patient with an atraumatic unilateral adrenal hemorrhage without a known coagulopathy Case presentation: A 51-year-old man with history of COPD and Reynaud's phenomenon presented to the hospital for severe right upper quadrant pain. CT of the abdomen demonstrated a right adrenal hemorrhage of 5.2×4.0×2.6 cm in size, for which Endocrinology was consulted. The patient denied recent trauma or anticoagulation use. Physical examination exhibited generalized abdominal tenderness, without hypotension, or symptoms of acute adrenal insufficiency. Biochemical evaluation showed an AM Cortisol level of 14.3 ug/dL (4.2 - 22.4 ug/dL) and ACTH 67.1 pg/mL (7.2 - 63.3 pg/mL). MRI abdomen showed a decrease in size of the hemorrhage measuring 3.1×1.7×5.2 cm. He was referred to Hematology/Oncology to evaluate for coagulopathy which was unrevealing. About one month from hospital discharge, the patient reported voice hoarseness and was diagnosed with moderately differentiated keratinizing squamous cell carcinoma of larynx. Ten months later PET-CT scan showed hypermetabolic laryngeal mass with bilateral cervical lymphadenopathy without evidence of adrenal gland metastasis with resolution of adrenal hemorrhage, indicative that the hemorrhagic episode is unrelated to this newly diagnosed malignancy. Discussion Adrenal hemorrhage is a rare disorder that overall is associated with a 10-20% mortality rate, it is usually classified as traumatic and no traumatic. Most times it is caused by secondary disorders such as trauma, surgery, anticoagulants, infections, but in rare instances is idiopathic. Clinical manifestations of adrenal hemorrhages vary depending on extension of the hemorrhage and early diagnosis is crucial for better outcomes. As per current guidelines, assessment for adrenal insufficiency including hemodynamics, biochemical evaluation and imaging is paramount. To date, clear etiology of primary adrenal hemorrhage is lacking. This case demonstrated an unusual presentation of idiopathic unilateral adrenal hemorrhage without evidence of adrenal insufficiency. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

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.

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.

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.

659 Unilateral Infarction of Adrenal Gland During Pregnancy: A Case Report and Important Learning Point

Abstract Background Abdominal pain in pregnancy offers a challenge for the General surgeon. Unilateral adrenal infarction is an extremely rare event. Case presentation: We report the case of an obese 23-year-old pregnant female G4 P1 + 2 diagnosed with unilateral adrenal infarction and hemorrhage. She presented at 34 + 5 weeks with severe RUQ and flank pain under the obstetric team. After initially being discharged, she later returned with intractable pain. Examination and initial investigations (USS KUB and abdomen) were inconclusive. She was empirically treated for pylonephritis. During the night she underwent emergency c-section due to uncontrollable pain. Subsequently, a CT abdomen demonstrated a unilateral right adrenal infarct with hemorrhage. Discussion: Unilateral adrenal infarction often leads to a delay in diagnosis and should be part of differential diagnosis in patients with severe RUQ pain (1.3%). It is a rare event diagnosed generally by CT or MRI scan showing attenuation or swelling of adrenal glands. Physiologically it is due to the state of venous circulation during pregnancy alongside others coagulation risks factor. Learning point: To consider adrenal infarction with severe RUQ pain when first line diagnosis normal. Key Investigations: MRI during pregnancy and CT AP after. Discussion in MDT and screen for coagulation disorder.

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.

Bilateral Adrenal Hemorrhage and Coagulation Laboratory Abnormalities: A Case Report of a Man with Enigmatic Clinical Features.

Background: bilateral adrenal hemorrhage can cause adrenal insufficiency. Antiphospholipid syndrome (APS) is considered a rare etiology of bilateral adrenal hemorrhage with a relatively small number of case reports. APS can be secondary to other autoimmune diseases such as SLE in which cardiac manifestations are common.
 Case presentation: a fifty-four-year-old male presents with left flank pain as a result of unilateral adrenal hemorrhage, a few days later, bilateral hemorrhage is documented in the presence of abnormal coagulation state and other laboratory clues. APS diagnosis was established.
 Coexisting chest pain accompanied by diffused ST elevation, long QT, slightly high troponin with a high pro-BNP, in addition to echo’s findings such abnormal regional wall abnormality and the absence of pericardial effusion made the case more interesting, differential diagnosis was proposed in accordance.
 Conclusion: bilateral hemorrhage in APS considered rare. Requiring a high index of clinical suspicion. Particularly when it is the initial manifestation of APS as in our case. Underlying autoimmune diseases should be screened actively, especially when other unexplained manifestations are presented.

SUN-163 Metastatic Spindle Cell Sarcoma Unmasked by Bilateral Adrenal Hemorrhage Resulting in Adrenal Insufficiency

Introduction:Adrenal hemorrhage (AH) is rare and can be life-threatening when bilateral AH causes adrenal insufficiency (AI). Risk factors include trauma, stress, sepsis, anticoagulant and antiplatelet use, hematologic disorders, and underlying adrenal tumors. We describe a patient whose bilateral AH led to a diagnosis of an underlying malignancy and caused AI.Clinical case:A 71-year-old man with well-controlled HIV presented with fatigue, weight loss, and acute lower abdominal pain.Four months prior to presentation, he underwent hip arthroplasty. His post-operative course was complicated by multiple pulmonary emboli and a new left 11.6 x 7.3 x 8.9 cm cystic retroperitoneal lesion with a density of 29 Hounsfield units on CT, thought to be a pancreatic pseudocyst or adrenal or retroperitoneal hemorrhage. Since the size remained stable on repeat CT three days later, he was discharged on rivaroxaban. On the day of presentation, he acutely developed severe abdominal and back pain. CT scan revealed a new 8.0 x 7.8 x 7.8 cm right adrenal collection and increased size of the prior left adrenal lesion to 13.1 x 10.6 x 13.0 cm. MRI confirmed bilateral adrenal masses with intralesional AH, as well as numerous peritoneal and retroperitoneal implants not noted on prior imaging.He remained stable and was managed non-operatively. Sodium (Na) and potassium (K) ranged 134-138 mmol/L (135-145) and 3.7-4.3 mmol/L (3.5-5.1), respectively. On presentation, morning cortisol and ACTH were 11 ug/dL and 27 ng/L (6-50), respectively, with an undetectable aldosterone and PRA 0.65 ng/mL/hr (0.25-5.8). Subsequent ACTH levels were 71 and 102 ng/L, and cortisol levels were 12 and 14 ug/dL. ACTH-stimulated cortisol was 15 ug/dL and free cortisol was 0.88 ug/dL. Plasma metanephrines were normal. Hydrocortisone was started and anticoagulation was held indefinitely. Biopsy of a retroperitoneal implant revealed metastatic spindle cell sarcoma.Three weeks later, given a persistently low Na of 134 mmol/L and increased K of 4.7 mmol/L, although blood pressure and heart rate were normal, he was empirically started on fludrocortisone. He followed up with oncology and was started on palliative chemotherapy.Clinical lessons:AH should prompt evaluation for an underlying etiology. In our patient, we suspect he already had a unilateral adrenal metastasis causing the initial unilateral AH, as he had no other risk factor. Four months later, the subsequent bilateral AH was likely caused by further metastatic spread and exacerbated by anticoagulation therapy.This case also suggests that AH may preferentially affect the zona fasciculata of the adrenal cortex and cause glucocorticoid deficiency, a phenomenon which has been noted on prior case reports. Our patient only needed hydrocortisone replacement initially, followed by fludrocortisone replacement three weeks later.

Diagnosis and treatment of adrenal hemorrhage

Objective To investigate the diagnosis and therapy by improving the further understanding of adrenal hemorrhage. Methods The clinical data of 12 cases of adrenal hemorrhage confirmed by pathology admitted to the First Hospital of China Medical University from October 2006 to October 2017 were retrospectively analyzed. Observe the patient′s clinical manifestations, imaging features, treatment methods and prognosis. Results All 12 cases were unilateral adrenal hemorrhage, 8 cases manifested lumbago in troubled side, 2 cases manifested abdominal pain, and 2 cases were found during physical examination incidentally with no obvious symptoms. Ultrasound-B was performed in 10 cases, revealed low echo of masses in 5 cases, mixed echo of masses in 2 cases, cystic echo of masses in 2 cases, and no abnormality in 1 case. All 12 cases were scanned by CT, 9 cases showed cystic masses with mixed density, and 3 cases showed solid masses. The value of plain CT ranged from 31 HU to 77 HU, no obvious enhancement was found in enhanced scan. One case was scanned by MRI, showed round mass in left adrenal gland, with uneven signal. The main signal was iso-signal in T1-weighted and T2-weighted. Six cases underwent adrenal and mass resection through the 11th rib, 3 cases underwent retroperitoneoscopic adrenalectomy, 2 cases underwent abdominal exploration and accepted adrenalectomy and hematoma removal, and 1 case was discharged after conservative treatment because of surgery contraindication. 11 cases of the pathology of postoperation were adrenal hemorrhage. Conclusions Preoperative diagnosis of adrenal hemorrhage is relatively difficult, ultrasound-B, CT, and MRI examination can help diagnose.Surgical treatment should be performed for patients who can tolerate surgery and with larger hematoma (>5 cm). Key words: Adrenal glands; Hemorrhage; Diagnosis; Therapy

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

ObjectiveTo 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 MethodsThis 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.ResultsSix 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.ConclusionAdrenal 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.

Successful Conservative Management of Spontaneous Unilateral Adrenal Hemorrhage in Pregnancy

Successful Conservative Management of Spontaneous Unilateral Adrenal Hemorrhage in Pregnancy