Endocrine Abstracts

Adrenal haemorrhage is a serious condition that can result in adrenal insufficiency, shock, acute adrenal crisis, and mortality if not managed with adequate treatment. Hereby we present two cases of non-traumatic bilateral adrenal haemorrhage highlighting their management during the acute phase.

Case 1: 57 year old female presented due to chest pain, palpitations and troponin rise with a background history of antiphospholipid syndrome on anticoagulation. She was treated as acute myocarditis. A CT abdomen was done after an episode of abdominal pain which showed bilateral adrenal haemorrhage. She remained haemodynamically stable with no drop in haemoglobin levels. Anticoagulant effect of warfarin was reversed with intravenous phytomenadione and dried prothrombin complex. She developed an acute left leg DVT after a couple of days and was managed on the lines of catastrophic antiphospholipid syndrome treated high dose of prednisolone and mycophenolate mofetil. Subsequent short synacthen test done after weaning of prednisolone confirmed adrenal insufficiency and she has maintained on replacement hydrocortisone. Repeat cross-sectional imaging was planned in three months to confirm resolution and exclude underlying adrenal pathologyCase 2: 55 year old male presented with right sided flank pain for one week. There was no history of trauma, weight loss, anticoagulation use and clinically no evidence of infection or sepsis. A CT abdomen showed bilateral adrenal enlargement with features in keeping with haemorrhage and small retroperitoneal rupture on the right. Given the haemodynamic stability along with stable serial haemoglobin levels, it was adjudged that non-surgical conservative management is appropriate in this case. Due to the bilateral nature of the disease he was started on replacement hydrocortisone which was subsequently stopped post a normal short synacthen test. Due to extensive past history of smoking a CT chest was conducted that showed 2 right lung lesions. His imaging was discussed in the local Lung and Adrenal MDT with a plan for short interval CT for the lung lesions followed by diagnostic investigation if required. Biochemical test for hyperfunction and repeat cross sectional adrenal imaging was planned after 3 months of the acute phase. In conclusion, bilateral adrenal haemorrhage can be secondary to various aetiologies. These cases can be managed conservatively if there is no evidence of persistent bleeding and haemodynamic instability. Further investigations after resolution of bleeding is required to determine the functional status and reassess the lesion on imaging.