Endocrine Abstracts

Introduction: Severe haemorrhage from an adenoma is rare and potentially fatal. We report an unusual case of idiopathic unilateral severe adrenal haemorrhage from a non-functioning adrenal adenoma which was incidentally discovered 12 years earlier.

Case Presentation: A 59-year-old female was admitted to the hospital for a severe sudden onset of abdominal pain associated with vomiting. About 12 years ago, she was found incidentally to have a left adrenal adenoma of 2 × 1.7 cm of 8 Hounsfield Unit when she underwent CT abdomen investigating for anaemia. The adrenal hormonal work up of 24 h urine catecholamine and metanephrine, 24 h urine free cortisol and aldosterone-renin were unremarkable. A repeat CT scan at 8 months later showed a stable adrenal lesion and she was discharged to her general practitioner. Her only other past medical history was diet-controlled hyperlipidaemia. She did not have hypertension, diabetes or obesity and did not take any medications. She did not have any symptoms to suggest pheochromocytoma. She denied any weight changes, fever or trauma. An urgent CT scan revealed a 9.7 × 7.2 cm acute haematoma in the left upper quadrant of the abdomen, likely related to a ruptured adrenal nodule. Her blood pressure inpatient was raised at 142–189/70–80 mmHg, likely due to the catecholamines release from adrenal haemorrhage. She was started on doxazosin to maintain normotension. 24 h urine catecholamines and metanephrines collected at 2nd day of admission were mildly raised which was appropriate for that level of stress (<1.5 times upper limit of normal). Her plasma free metanephrine (<0.20 nmol/l) and free normetanephrine (0.5 nmol/l) were normal. She did not have biochemical evidence of Cushing syndrome, hyperaldosteronism or hyperandrogenism. MRI adrenals performed on day 7 confirmed the enhancing left adrenal mass as the source of haemorrhage. Her abdominal pain resolved within the week and she was discharged well. Serial imaging of the adrenals using CT scan at 4 weeks and 5 months showed that the left adrenal size became progressively smaller, at 7 × 3.3 cm and 2.1 × 2 cm respectively. Her blood pressure control improved and she required only a low dose nifedipine 30 mg for control of hypertension at 5 months of follow up.

Conclusion: Idiopathic unprovoked adrenal haemorrhage from a non-functioning adrenal adenoma 12 years later can occur, suggesting that a longer follow up of adrenal adenoma should be considered before discharge.