Endocrine Abstracts

Bilateral adrenal haemorrhage is an uncommon but life-threatening condition which may result from trauma, sepsis, coagulopathy, underlying tumour or autoimmune conditions. We present a 62-year-old female with a history of well controlled hypertension and asthma who was admitted with sudden onset epigastric pain and suspected cholecystitis. She received her first dose of Astrazeneca (AZ) Covid-19 vaccine seven days prior to onset of symptoms. Her systolic blood pressure was more than 200mmHg initially, which normalized on day three of admission and amlodipine was discontinued. There were no clinical features of Cushing’s syndrome, phaeochromocytoma or skin hyperpigmentation. Investigations revealed normal full blood count. Abdominal ultrasound and subsequent MRCP identified no pathology. CT abdomen revealed bilateral adrenal oedema suggestive of haemorrhage/infarction. Vasculitis and autoantibody screen was normal. Both 9am and random cortisol were < 100nmol/l, consistent with adrenal insufficiency. Given that her symptoms had resolved, she was discharged on oral steroid replacement with urgent endocrine outpatient follow-up. A short synacthen test after holding fluticasone inhaler (four weeks later) confirmed adrenal insufficiency with a peak cortisol of 59nmol/l (>500). Significantly elevated basal ACTH, raised renin activity and undetectable aldosterone, adrenal androgens, 17-hydroxyprogesterone, plasma metadrenaline and 3-methoxytyramine confirmed primary adrenal failure. Plasma normetadrenaline was normal. Interval CT adrenal at three months showed resolution of adrenal haemorrhage and patient is stable on glucocorticoid and mineralocorticoid replacement. Spontaneous bilateral adrenal haemorrhage is rare and secondary causes must be excluded. We postulate that this may be a rare complication of the AZ Covid-19 vaccine, which has been associated with thromboembolic phenomena. Up to 12 cases of adrenal infarction, haemorrhage and thrombosis linked to AZ vaccine have been reported to UK’s yellow card scheme over the last six months. Clinicians should have high index of suspicion to diagnose such a rare but potentially life-threatening complication.