Endocrine Abstracts

Introduction

Severe hemorrhage is a rare and potentially lethal manifestation of adrenal gland nor usually associated with primary aldosteronism.

Material and methods

Review of the patient’s clinical record and of the relevant literature.

Case report

A 47-year-old male with personal history of asthma, untreated stage II hypertension, obesity, dysphagia associated with diffuse esophageal spasm and head trauma with subdural hematoma (several years ago) came to the Emergency Room of our Hospital with sudden periumbilical pain radiating to the left renal fossa, after a strenuous exercise. He showed malaise, peripheral hypoperfusion, diaphoresis and high blood pressure. His renal function was previously normal but plasma creatinine in the ER was 1.6 mg/dl and the estimated glomerular filtration rate was 46.5 ml/min/1.73 m². The abdominal CT scan revealed a large (8 × 12 × 19 cm) retroperitoneal hematoma apparently flowing from the left adrenal which showed active bleeding, with a possible underlying lesion. The patient suffered anemization requiring successive blood transfusions plus continuous perfusion with solinitrine and urapidil to control blood pressure. The physical examination showed the persistence of high blood pressure and a painful left hemiabdomen with a rigid left flank. In the context of hemorrhagic shock, the lab tests showed: plasma aldosterone 657 pg/ml (PRA not available), potassium 3.48 mEq/l, metanephrine 165 pg/ml and normetanephrine 619 pg/ml. After hemodynamic stabilization aldosterone was 130 pg/ml, PRA 0.4 ng/ml/min and ARR 32.5; metanephrine 26 pg/ml and normetanephrine 76 pg/ml, with normal ionogram, TSH 4.18 μUI/ml and cortisol 16 μg/dl. A PET-CT scan ruled out adrenal malignancy. The patient developed hypertensive encephalopathy with hypertensive retinopathy, and persistence of the renal insufficiency associated to nephroangiosclerosis. He is presently being treated with carvedilol, doxazosin and amlodipine, with acceptable blood pressure control. A follow-up abdominal MRI showed partial persistence of the hematoma, and absence of an underlying adrenal lesion. Primary aldosteronism has not been ruled out, and a confirmation test after carvedilol withdrawal is scheduled.

Conclusion

Adrenal hemorrhage is infrequent, and has not usually been reported as a complication of primary aldosteronism. The rapid normalization of the plasma aldosterone and metanephrines after haemodynamic stabilization is also noteworthy, and reminds us that the diagnostic workup of primary aldosteronism and pheochromocytoma/paraganglioma must wait until the patient is stable.