Endocrine Abstracts

Adrenal haemorrhage is comparatively rare. A 64-year-old female presented with acute right sided abdominal and chest pain shortly after a left knee replacement. She had recently started treatment dose low molecular weight heparin for presumed DVT for persistent pain in the left knee. A subsequent Doppler study of left leg was negative for DVT but an abdominal US revealed a solid lesion at the upper pole of the left kidney. CT urography showed large bilateral adrenal masses. No clinical or biochemical evidence of adrenal endocrine excess or deficiency was demonstrated. She became persistently pyrexial during admission, but no source of sepsis was found. At endocrine review, repeat CT scan with adrenal washout protocol demonstrated bilateral adrenal masses that had markedly reduced in size suggesting resolving bilateral adrenal haemorrhage. A 0900h plasma cortisol level, urinary normetadrenaline and metadrenaline excretion and a plasma aldosterone:renin ratio were all normal. Adrenal imaging review was consistent with bilateral adrenal haemorrhage (BAH) with no evidence of underlying adrenal tumour.

The incidence of BAH is estimated to be ~4.7–6.2 cases/million. Nontraumatic adrenal gland haemorrhage is rare. Causes include idiopathic, stress, haemorrhagic coagulopathy, neonatal stress, or underlying adrenal tumours. The peri-operative period after orthopaedic surgery is associated with an increased risk of a haemorrhagic event. From documented case reports, adrenal haemorrhages after orthopaedic procedures commonly present with abdominal pain and pyrexia. CT is the recommended choice of modality to diagnose adrenal haemorrhage. When adrenal insufficiency complicates BAH immediate treatment with replacement corticosteroids is mandatory.

This case demonstrates a rare case of post-operative BAH. It underlines the importance of recognising adrenal haemorrhage in the differential diagnosis of unexplained abdominal pain and pyrexia since a missed diagnosis could be fatal.