Endocrine Abstracts

Background: A 73-year-old female presented to the hospital with a 3-day history of right upper quadrant abdominal pain and episodes of vomiting. Her past medical history included insulin treated Type 2 diabetes diabetes, deep venous thrombosis for which she was on rivaroxaban, COPD, right leg angioplasty and previous p-ANCA vasculitis. She also had flank tenderness and was noted to be hypertensive with a blood pressure of 225/93mmHg. A CT scan of the abdomen identified a new 4 cm right-sided indeterminate adrenal mass since her previous imaging where adrenal glands were reported normal in 2019. She became hypotensive and was treated with intravenous hydrocortisone for suspected unilateral adrenal haemorrhage. Two days later, she started to experience pain in the left flank. A dedicated MRI adrenal study showed the emergence of a new left adrenal lesion, similar in size, signal and characteristic to the lesion on the right adrenal gland. Synacthen test showed inadequate response, Aldosterone/renin ratio and adrenal androgens were not elevated. Whole body PET scan did not show any FDG avid lesions in the adrenal glands. Considering the acute history, rivaroxaban anticoagulation use, p-ANCA vasculitis, and new progressive bilateral adrenal lesions, the diagnosis was adrenal insufficiency secondary to bilateral adrenal haemorrhage. Rivaroxaban was replaced with warfarin after appropriate discussion with the haematology and adrenal MDT.

Discussion: Acute adrenal haemorrhage (adrenal apoplexy) is a rare, potentially life-threatening cause of adrenal crisis. Diagnosis can be challenging however needs to be considered especially with risk factors that include the use of anticoagulants as well as vasculitis. Abdominal CT can be useful in detecting haemorrhage within the adrenal glands. Management, after treatment of the adrenal insufficiency, often requires a multidisciplinary approach due to the complexity of the confounding risk factors. Surveillance imaging post haemorrhage can be used to monitor for resolution of the hematoma as well as investigating if there was any other underlying cause of adrenal enlargement.

Learning Points: 1. Novel anticoagulant therapy can be a risk factor for developing the rare condition of bilateral adrenal haemorrhage especially in patients with a background of vasculitis. 2. Cortisol and catecholamines released by the expanding hematoma may initially precipitate hypertension and therefore adrenal insufficiency symptoms may be a late presenting feature. 3. Angiography and embolisation of adrenal haemorrhages may provide better outcomes compared with traditional surgical laparotomy and should be considered if the retroperitoneal bleeding is unresponsive to conservative management.