Post-operative bilateral adrenal haemorrhage: A case report

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

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

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 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.

Anticoagulation-induced unilateral adrenal haemorrhage and pseudoaneurysm

Spontaneous unilateral adrenal haemorrhage (AH) is extremely rare. Its presentation is usually non-specific and requires a high degree of suspicion as it is associated with high morbidity and mortality if diagnosis is delayed. Hereby, we present a case of 67-year-old man with significant cardiac history presented with right-sided chest pain and non-specific abdominal pain. He was previously treated for non-ST elevation myocardial infarction 5 days ago prior to the current presentation. CT scan of abdomen and pelvis demonstrated a right-sided active AH. The patient subsequently underwent digital subtraction angiography. Angio-embolisation was attempted for the pseudoaneurysm but failed due to spasm of the vessel. He was managed conservatively and discharged after clinical improvement. Clinic review 6 months later showed significant size reduction of the pseudoaneurysm.

Bilateral adrenal hemorrhage after hip arthroplasty: an initially misdiagnosed case

Background

Bilateral adrenal hemorrhage (BAH) is a rare but potentially catastrophic condition. Its clinical manifestation is often non-specific and sometimes difficult to be diagnosed in time.

Case summary

A 57-year-old woman, who presented with severe fatigue, nausea and vomiting after left hip arthroplasty due to her femoral neck fracture in a local hospital, was transferred to our medical center. Laboratory results revealed significant hyponatremia, low serum cortisol and elevated serum ACTH. Computed tomography (CT) showed a bilateral adrenal mass, measured 3.6 × 2.7 cm on the left and 3.4 × 2.3 cm on the right. Further magnetic resonance imaging (MRI) confirmed the diagnosis of BAH. The patient was prescribed with oral prednisolone acetate, 5 mg, tid, and her condition improved gradually. Nine months after, the patient was in good condition with 5 mg prednisolone acetate per day. CT revealed a clearly shrunken adrenal mass compared with 9 months ago.

Conclusions

This case illustrates the difficulty in making the diagnosis of BAH with atypical presentation. Such cases necessitate greater alertness on the part of the clinician and require rapid diagnosis and prompt glucocorticoid replacement for better clinical outcomes.

A Rare Case of Bilateral Adrenal Hemorrhage

Bilateral adrenal hemorrhage (BAH) is a rare but potentially fatal entity that carries a mortality rate of 15%. Most cases are associated with sepsis, antiphospholipid syndrome, the use of anticoagulants, as well as trauma and surgery. In this case report, we present a case of BAH in a previously healthy man with a recent history of corticosteroid use. Our case emphasizes the ambiguous clinical presentation of BAH, which poses a challenge in the establishment of a correct diagnosis. We also illustrate the pathophysiology, diagnosis, and subsequent therapeutic approach to this rare clinical entity.

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.