Bilateral massive adrenal hemorrhage. Assessment of putative risk factors by the case-control method

Clinical characteristics and outcomes of adrenal hemorrhage

BACKGROUND

Although uncommon, adrenal hemorrhage has multiple etiologies. Because clinical characteristics, management, and outcomes of patients with adrenal hemorrhage are inadequately described, we examined the underlying etiology, need for intervention, evolution of imaging characteristics, and adequacy of subsequent evaluation.

METHODS

We performed a retrospective review of patients diagnosed with adrenal hemorrhage (radiologist-confirmed density consistent with hemorrhage on computed tomography) from 2005 to 2021 at a university-based institution. Demographic characteristics, hemorrhage etiology, and subsequent follow-up were analyzed.

RESULTS

Of 193 adrenal hemorrhage patients, the mean age was 49.2 ± 18.3 years, and 35% were female. Clinical presentations included trauma (47%), abdominal or flank pain (28%), incidental findings on imaging acquired for other reasons (12%), postoperative complication (8%), or shock (3%). Hemorrhage outside of the gland was present in 62% of patients. Unilateral hemorrhage was more frequent (93%) than bilateral (7%). A total of 12% of patients had nodules, but only 70% of these were identified on initial imaging, and only 43% had hormonal evaluation. Of 7 patients who had adrenalectomy or biopsy, pathology was either benign (57%) or nonadrenal malignancy (43%). No adrenocortical carcinomas were identified. Follow-up imaging was performed in 56% of patients and revealed decreased, stable, resolved, or increased adrenal hemorrhage size in 39%, 19%, 30%, and 12% of patients, respectively.

CONCLUSION

Adrenal hemorrhage is secondary to multiple etiologies, most commonly trauma. In the setting of adrenal hemorrhage, many adrenal nodules were not identified on initial imaging. Only a minority of patients with nodules underwent "complete" biochemical evaluation. Follow-up imaging may improve the identification of underlying nodules needing hormonal evaluation.

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.

Characteristics of Adrenal Hemorrhage: A Single Clinic's Experience

<b>Introduction:</b> Adrenal hemorrhage (AH) is a very rare and potentially life-threatening disease which may be secondary to trauma or of non-traumatic etiology.<b>Aim:</b> The aim of the study was to present the characteristics and management of adrenal hemorrhage and show that adrenal hemorrhage is more common than expected and that the clinical symptoms are not specific.<b>Materials and methods:</b> This retrospective study involved 199 patients with postoperative diagnosis of adrenal hemorrhage.<b>Discussion:</b> The factors identified as potential causes of adrenal hemorrhage are adrenocortical carcinoma, pheochromocytoma, and adrenal adenoma. The study group included 199 patients with postoperative diagnosis of AH. It showed that all patients with postoperative diagnosis had pheochromocytoma (n = 54), adrenal adenoma (n = 68), or adenocarcinoma (n = 17). If we look more careful at the results, we can find only 30% of patients (n = 39) with preoperative diagnosis of AH. This group of 39 patients was prepared for expedited surgery. In this group of patients, the preoperative diagnosis of AH was pheochromocytoma 28% (n = 11), adenocarcinoma (n = 4), and adrenal adenoma (n = 9).<b>Conclusions:</b> Bleeding into adrenal tumors is still an insufficiently understood topic due to its unpredictability and, as can be seen in our material, of varying severity. Out of 199 patients, only 30% (n = 39) were prepared for surgery with a preoperative diagnosis of AH; most of them had pheochromocytoma. We suggest that is very important to prepare patients for surgery with a preoperative diagnosis of AH using α-adrenoreceptor antagonists. Prolongation of the diagnostic process (time between the imaging examination and the surgery) may result in the disease progressing and adrenal bleeding.

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

OBJECTIVE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Perinatal asphyxia and hypothermic treatment from the endocrine perspective

Introduction

Perinatal asphyxia is one of the three most important causes of neonatal mortality and morbidity. Therapeutic hypothermia represents the standard treatment for infants with moderate-severe perinatal asphyxia, resulting in reduction in the mortality and major neurodevelopmental disability. So far, data in the literature focusing on the endocrine aspects of both asphyxia and hypothermia treatment at birth are scanty, and many aspects are still debated. Aim of this narrative review is to summarize the current knowledge regarding the short- and long-term effects of perinatal asphyxia and of hypothermia treatment on the endocrine system, thus providing suggestions for improving the management of asphyxiated children.

Results

Involvement of the endocrine system (especially glucose and electrolyte disturbances, adrenal hemorrhage, non-thyroidal illness syndrome) can occur in a variable percentage of subjects with perinatal asphyxia, potentially affecting mortality as well as neurological outcome. Hypothermia may also affect endocrine homeostasis, leading to a decreased incidence of hypocalcemia and an increased risk of dilutional hyponatremia and hypercalcemia.

Conclusions

Metabolic abnormalities in the context of perinatal asphyxia are important modifiable factors that may be associated with a worse outcome. Therefore, clinicians should be aware of the possible occurrence of endocrine complication, in order to establish appropriate screening protocols and allow timely treatment.

Approach to the Patient With Adrenal Hemorrhage

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

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

OBJECTIVE

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

DESIGN

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

RESULTS

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

CONCLUSION

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

Acute Spontaneous Bilateral Adrenal Hemorrhage Presenting as Hyponatremia

Bilateral adrenal hemorrhage is a very unusual cause of severe adrenal insufficiency and hyponatremia. It can result from trauma, infections, or antiphospholipid antibody syndrome and can be fatal if not diagnosed and treated early. Here, we present a 58-year-old Caucasian man with fatigue, altered sensorium, bradycardia, and hypotension. He denied any abdominal pain, recent trauma, or anti-platelet or anti-coagulation agents. His laboratory workup showed hyponatremia with low serum cortisol levels. He was further worked up and underwent computerized tomography (CT) of the abdomen, which showed bilateral adrenal hemorrhage. He was treated with intravenous (IV) steroids followed by oral hydrocortisone and fludrocortisone. His symptoms resolved, and he was safely discharged home. Asymptomatic bilateral adrenal hemorrhage is a sporadic disease, and it should be in the differential diagnosis for disproportionately sick people with other adrenal insufficiency features.

Presumptive nontraumatic adrenal hemorrhage preceding hypoadrenocorticism in a dog

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

Bilateral Adrenal Hemorrhage Following Femoral Hip Hemiarthroplasty: A Case Report

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

Unilateral Adrenal Hemorrhage: A Rare Complication of Anticoagulant Use

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

A Successful Conservative Management of Spontaneous Adrenal Hemorrhage (SAH) in Pregnancy: A Case Report

It Is well known that abdominal pain during pregnancy has a broad differential diagnosis, which includes spontaneous adrenal hemorrhage (SAH), a rarely reported phenomenon in the literature, defined as an acute hemorrhage into the adrenal gland during pregnancy in the absence of a clear cause. Physicians should have a high suspicion for it due to the potentially life-threatening complications, as they present usually with a non-specific presentation. We present a case of symptomatic SAH in the third trimester of pregnancy that was successfully managed conservatively.

Primary adrenal insufficiency due to bilateral adrenal infarction in COVID-19: a case report

CONTEXT

Coronavirus disease 2019 (COVID-19) is a proinflammatory and prothrombotic condition, but its impact on adrenal function has not been adequately evaluated.

CASE REPORT

A 46-year-old woman presented with abdominal pain, hypotension, skin hyperpigmentation after COVID-19 infection. The patient had hyponatremia, serum cortisol <1.0 ug/dL, ACTH of 807 pg/mL and aldosterone <3 ng/dL. Computed tomography (CT) findings of adrenal enlargement with no parenchymal and minimal peripheral capsular enhancement after contrast were consistent with bilateral adrenal infarction. The patient had autoimmune hepatitis and positive antiphospholipid antibodies, but no previous thrombotic events. The patient was treated with intravenous hydrocortisone, followed by oral hydrocortisone and fludrocortisone.

DISCUSSION

Among 115 articles, we identified nine articles, including case reports, of new-onset adrenal insufficiency and/or adrenal hemorrhage/infarction on CT in COVID-19. Adrenal insufficiency was hormonally diagnosed in five cases, but ACTH levels were measured in only three cases (high in one case and normal/low in other two cases). Bilateral adrenal non- or hemorrhagic infarction was identified in five reports (two had adrenal insufficiency, two had normal cortisol levels and one case had no data). Interestingly, the only case with well-characterized new-onset acute primary adrenal insufficiency after COVID-19 had a previous diagnosis of antiphospholipid syndrome. In our case, antiphospholipid syndrome diagnosis was established only after the adrenal infarction triggered by COVID-19.

CONCLUSIONS

Our findings support the association between bilateral adrenal infarction and antiphospholipid syndrome triggered by COVID-19. Therefore, patients with positive antiphospholipid antibodies should be closely monitored for symptoms or signs of acute adrenal insufficiency during COVID-19.

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

OBJECTIVE

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

CASE SUMMARY

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

NEW OR UNIQUE INFORMATION

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

Can we differentiate neoplastic and non-neoplastic spontaneous adrenal bleeding? Imaging findings with radiopathologic correlation

Spontaneous adrenal bleeding is a rare clinical event with non-specific clinical features. Life-threatening bleeding in the adrenal glands may be promptly diagnosed with imaging. Computed tomography (CT) is generally the first imaging modality to be used in these patients. However, in the acute phase of bleeding, it may be difficult to detect the underlying mass from the large hematoma. In these patients, additional imaging studies such as magnetic resonance imaging or positron emission tomography/CT may be utilized to rule out a neoplastic mass as the source of bleeding. In patients where an underlying neoplastic mass could not be identified at the time of initial diagnosis, follow-up imaging may be helpful after the acute phase subsides.

Medical Management of Heparin-Induced Thrombocytopenia Causing Acute Adrenal Insufficiency

Heparin-induced thrombocytopenia is an immune-mediated reaction to heparin and heparin analogs, which results in an acquired hypercoagulability syndrome resulting in paradoxical arterial and venous thrombosis leading to thrombocytopenia. Organs with high vascularity, such as the adrenal glands, are at an increased risk of injury in heparin-induced thrombocytopenia due to thrombus formation in the adrenal vein causing adrenal insufficiency. The standard of treatment remains discontinuation of heparin and heparin analogs and starting corticosteroids and non-heparin antithrombotic therapy such as argatroban.

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

•

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.

•

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 haemorrhage as a complication of COVID-19 infection

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

Case Report: COVID-19 with Bilateral Adrenal Hemorrhage

A 70-year-old Dominican Republic man presented with lower back pain for 10 days. Fifteen days before pain onset, he had low-grade fever, chills, and asthenia, and 4 days before admission, he had constipation, malaise, generalized weakness, anorexia, nausea, and vomiting. On admission, the patient was afebrile and hypotensive, with a heart rate of 105 and an oxyhemoglobin saturation on room air of 95%. Hyponatremia, lymphopenia, elevated C-reactive protein, and ferritin were observed in complementary tests. Computed tomography (CT) scan showed findings consistent with COVID-19 bilateral bronchopneumonia, and an increase in size and blurring (loss of the Y shape) of both adrenals indicative of acute bilateral adrenal hemorrhage. The patient tested negative by reverse transcription polymerase chain reaction (RT-PCR) of nasopharyngeal swab, yet positive for IgG and IgM by ELISA, suggesting COVID-19 diagnosis.

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.

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

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

BILATERAL ADRENAL HEMORRHAGE WITH ADRENAL INSUFFICIENCY AFTER DALTEPARIN USE POST HIP ATHROPLASTIES

Objective

Multiple case reports have implicated the use of heparin for deep vein thrombosis (DVT) prophylaxis with bilateral adrenal hemorrhage. Only 1 previous report has described this with the low molecular weight product, dalteparin. We report a case following bilateral hip arthroplasties.

Methods

Clinical and laboratory data are presented.

Results

A 69-year-old woman underwent bilateral total hip arthroplasties with dalteparin 5,000 international units subcutaneously daily for 30 days postoperatively. The patient's past medical history was unremarkable. She was discharged 5 days post-surgery and required readmission 1 day later for epigastric pain, nausea, and vomiting. Her platelet count was 91 × 10⁹/L (normal, 150 to 400 × 10⁹/L). She was discharged after 4 days with pain resolution. She presented 4 weeks later with nausea and vomiting for several days. Serum sodium was 123 mmol/L (normal, 133 to 145 mmol/L), potassium was 6.0 mmol/L (normal, 3.7 to 5.3 mmol/L), total calcium was 3.37 mmol/L (normal, 2.25 to 2.80 mmol/L), creatinine was 404 μmol/L (normal, 0 to 85 μmol/L), and her platelet count was normal. On short adrenocorticotropic hormone stimulation test, baseline plasma cortisol was 123 nmol/L and the peak was 129 nmol/L. She was treated with hydrocortisone, fludrocortisone, and 0.9% saline with resolution of symptoms and normalization of electrolytes, calcium, and renal function. Computed tomography showed bilateral adrenal masses. Core needle biopsy was consistent with necrosis. There were no bleeding disorders on hematologic work 3 months later. The most likely etiology of bilateral adrenal hemorrhage was heparin-induced thrombocytopenia from dalteparin.

Conclusion

This case highlights the importance of vigilance for the complication of bilateral adrenal hemorrhage with adrenal insufficiency in patients receiving dalteparin for DVT prophylaxis.

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.

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

Background

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

Methods

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

Results

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

Conclusions

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

A case report of spontaneous staphylococcal meningitis in a cynomolgus monkey

This report describes a suppurative meningitis in a young cynomolgus. The animal had neutrophil aggregation in the subarachnoid space and hemorrhage in bilateral adrenal glands. Staphylococcus was identified by FISH in brain. To our knowledge, this is the first case of staphylococcal meningitis with Waterhouse-Friderichsen syndrome in a cynomolgus monkey.

Hyperdehydroepiandrosterone in neonates with hypoxic ischemic encephalopathy and circulatory collapse

BACKGROUND

Circulatory collapse is a very common complication of the critical illnesses in neonates including neonates with hypoxic ischemic encephalopathy; it can be the end result and cause of death of several conditions. Often, despite treatment with fluid resuscitation and vasopressor agents, circulatory collapse persist, and blood pressure can remain critically low, compromising adequate blood flow to vital organs and brain. Low blood pressure has been associated with increased mortality.

METHOD

To investigate adrenal function in newborn infants who suffer from circulatory collapse during hypoxic ischemic encephalopathy. A total of 30 infants were analyzed in the study: 15 neonates in group A (neonates had hypoxic ischemic encephalopathy with vasopressor resistant hypotension) and 15 neonates in group B (neonates with hypoxic ischemic encephalopathy without vasopressor resistant hypotension). All the studied patients were subjected to history, examinations and laboratory investigation including serum cortisol concentrations and cortisol precursor's levels.

RESULTS

The cortisol concentrations did not differ significantly between the two groups: (12.9 ± 4.3) μg/dL and (12.1 ± 2.4) μg/dL in group A and group B, respectively. There are highly significant differences between groups A and B regarding Dehydroepiandrosterone (342.1 ± 101.3) μg/dL, (33.4 ± 16.5) μg/dL, respectively.

CONCLUSION

In this study, we noticed that cortisol concentrations did not differ between both groups in contrast to the expectation that neonates with critical illnesses should have higher cortisol concentrations than normal neonates. However, the marked increase in dehydroepiandrosterone DHEA may cause decrease cortisol function, so those neonates having accumulation of dehydroepiandrosterone may suffer from manifestation of adrenal insufficiency and vasopressor resistant hypotension in spite of normal cortisol level.

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.

Spontaneous Unilateral Adrenal Hemorrhage in Pregnancy

Spontaneous adrenal hemorrhage (SAH) is a serious medical condition associated with variable clinical presentation depending on the extent of the hemorrhage. Pregnancy-induced adrenal hemorrhage is poorly understood. A low cortisol level in the peripartum period with radiological findings is sufficient to establish the diagnosis. Prompt hormone replacement and supportive care to ensure good clinical outcomes is crucial. Due to the potentially life-threatening complications, physicians should have a high suspicion for adrenal hemorrhage when they evaluate patients with hypotension, fatigue, and abdominal pain during the peripartum period.

Streptococcus Pneumoniae Detection Long Time After Death in a Fatal Case of Waterhouse-Friderichsen Syndrome

We report a fatal case of Waterhouse-Friderichsen syndrome in a 64-year-old man. The diagnosis, suspected during the autopsy (performed 63 hours after death), was confirmed through the successful detection of Streptococcus pneumoniae DNA and antigens in samples (blood and liver) collected during the autopsy. These results conformed with blood cultures performed antemortem, which became available only the day after the autopsy. The case underlines the need to collect biological material (liver and blood samples) during autopsy for microbiological investigations, although the collection is performed a long time after the death, suggesting that a liver sample works for DNA and liver and blood work for Streptococcus pneumoniae antigen detection.

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.

[ADRENAL HEMORRHAGE: 6 CASES AND A REVIEW OF 57 REPORTED CASES]

PURPOSE

The guidelines on adrenal hemorrhage has not established in Japan. In this article, we discuss the management of adrenal hemorrhage.

OBJECTS AND METHODS

We experienced 6 patients from November 2004 to September 2013 in The University of Tokyo Hospital and The Fraternity Memorial Hospital, and we searched 57 cases already reported in Japan by using Japan Medical Abstracts Society (http://search.jamas.or.jp/). So we analyzed total 63 adrenal hemorrhage cases in Japan.

RESULTS

In 63 cases, 5 cases were performed TAE, 3 cases were performed emergent surgeries, 13 cases were managed conservatively and elective surgeries were performed in the other cases. 5 cases were fulfilled criteria for Hb < 10 g/dl and the maximum diameter of the hematoma > 10 cm. Of 5 cases, 4 cases were performed emergent hemostasis.

CONCLUSIONS

Adrenal hemorrhages caused by metastatic tumor tend to be serious anemia. In addition, the most patients with adrenal hemorrhages, who had Hb < 10 g/dl and the maximum diameter of the hematoma > 10 cm, required immediate medical treatment, e.g. TAE or surgical hemostasis.

Restoration of adrenal function after bilateral adrenal damage due to heparin-induced thrombocytopenia (HIT): a case report

Introduction

Patients with bilateral adrenal damage due to heparin-induced thrombocytopenia usually need lifelong steroid substitution. So far, no data exists about the natural evolution of such a condition, especially about adrenal function recovery and the real need for lifelong steroids.

Case presentation

An 81-year-old Caucasian woman with bilateral adrenal damage due to heparin-induced thrombocytopenia presented with fever and severe hypotension. Adrenal failure was confirmed biologically and radiologically. She eventually recovered her adrenal function, allowing for steroid withdrawal.

Conclusions

This case report addresses the different mechanisms of adrenal damage due to heparin-induced thrombocytopenia and its natural evolution with potential recovery. This should encourage clinicians to evaluate the real necessity for lifelong corticosteroid substitution in such a condition.

Bilateral adrenal hemorrhage in a total knee patient associated with enoxaparin usage

Bilateral adrenal hemorrhage is a rare but potentially catastrophic complication of chemoprophylaxis. We report a patient who underwent a total knee arthroplasty and subsequently developed bilateral adrenal hemorrhage from enoxaparin. Once the patient was diagnosed with acute adrenal insufficiency, corticosteroids were promptly started, and the patient made a dramatic recovery and did not suffer further complications.

Bilateral adrenal hemorrhage in a patient with myelodysplastic syndrome: value of MRI in the differential diagnosis

Bilateral adrenal hemorrhage is a rare potentially life-threatening event that occurs either in traumatic or nontraumatic conditions. The diagnosis is often complicated by its nonspecific presentation and its tendency to intervene in stressful critical illnesses. Due to many disorders in platelet function, hemorrhage is a major cause of morbidity and mortality in patients affected by myeloproliferative diseases. We report here the computed tomography and magnetic resonance imaging findings of a rare case of bilateral adrenal hemorrhage in a patient with myelodysplastic syndrome, emphasizing the importance of MRI in the differential diagnosis.

Renal small B-cell lymphoma with plasmacytic differentiation presenting with monoclonal gammopathy and disseminated intravascular coagulation syndrome

Primary renal lymphomas are very rare. However, the kidney may be a site of metastasis, usually from a disseminated aggressive lymphoma. A 58-year-old woman was brought to the medical facility due to acute mental confusion, severe hypotension, septic shock, and signs of disseminated intravascular coagulation. Laboratory tests showed severe leukopenia, renal failure, altered liver function, and elevated serum lactate dehydrogenase levels. Protein electrophoresis revealed hypergammaglobulinemia with a monoclonal peak of IgG lambda. The clinical outcome was fulminant and the patient died less than 24 hours after admission. Autopsy revealed an indolent B-cell lymphoma with extensive plasmacytic differentiation infiltrating the right renal sinus and involving the submandibular and sublingual glands, cervical and peri-aortic lymph nodes, multiple microscopic foci in pituitary and adrenal glands, lung, breast, liver, thyroid, and bone marrow. Numerous IgG4-positive plasma cells were detected by immunohistochemistry although other histological features of IgG4-related disease were missing. There was also extensive hemorrhagic necrosis of the adrenal glands and purulent cystitis, which was probably responsible for the septic shock. The authors concluded that the kidney was most likely the primary site of the indolent lymphoma, as that was the site with the largest tumor mass. Infiltration of other organs was considered as dissemination of the disease. The differential diagnosis with mucosa-associated lymphoid tissue and lymphoplasmacytic lymphoma is discussed.

Idiopathic spontaneous adrenal hemorrhage in the third trimester of pregnancy

Spontaneous adrenal hemorrhage (SAH) is seen in the absence of trauma or adrenal tumor in adrenal glands. The incidence of SAH has been reported from 0.14% to 1.1% and it usually involves the right gland. During pregnancy, idiopathic unilateral SAH has been reported rarely. We present a case which comes to emergency department with an acute abdominal pain and the test results showed spontaneous left SAH.

Acute adrenal failure following anticoagulation with dabigatran after hip replacement and thrombolysis for massive pulmonary embolism

A 75-year-old woman presented 9 days post-total hip replacement with sudden onset of shortness of breath and fever. She had been discharged taking dabigatran. The patient was treated for sepsis with antibiotics and fluids. However, she deteriorated and was transferred to the intensive care unit. Following a 10 s asystolic episode the patient was thrombolysed with alteplase for presumed massive pulmonary embolism. Initially, her blood pressure and oxygen saturation improved. However, over the next few days, she remained persistently hypotensive. A CT scan of her chest, abdomen and pelvis demonstrated bilateral adrenal haemorrhages. A short synacthen test confirmed acute adrenal failure.

Post-surgical hemorrhagic infarction of the adrenal gland as the first clinical manifestation of antiphospholipid syndrome after 43 years of antibody-positivity

We report on a male patient who tested positive for antiphospholipid antibodies for 43 years without thromboembolic manifestation of antiphospholipid syndrome (APS). He has been followed up in a prospective cohort study since 2001. Following his second hip replacement surgery, the patient developed acute adrenal failure due to bilateral hemorrhagic infarction. Prophylactic anticoagulation, surgery, or an immunological reaction to blood transfusion may have triggered this late and unusually located primary manifestation of APS in our patient.