Endocrine Abstracts

Background: Adrenal haemorrhage is a rare clinical presentation with an incidence of only 5 in 1,000,000 ^[1]. 10% of these are bilateral adrenal haemorrhages, which has very high mortality rate of 15 % ^[2]

Case summary: 22 years old female had C-section for persistent to breech presentation at term. She has a history of preterm delivery due to chorioamnionitis during previous pregnancy. Patient had about 1.2L post-partum haemorrhage. She deteriorated after 24 h of C-section, with hypotension pyrexia, and decreased urinary output. The blood result showed acute kidney injury (AKI), raised INR, raised procalcitonin>100ng/ml, severely deranged liver function tests, hyperkalaemia (K⁺ 6.9mmol/l) and hyponatremia (Na⁺ 129mmol/l). CT-abdomen showed bilateral acute adrenal haemorrhages. She was started on IV hydrocortisone along with treatment for post-partum haemorrhage, sepsis, and AKI in critical care. Following clinical improvement, hydrocortisone dose was reduced, and she had a short Synacthen test which showed subnormal response to Cosyntropin (cortisol of 207 nmol/l and 192 nmol/l) with raised ACTH of 102 ng/l. She was discharged on hydrocortisone 10/5/5 dose with outpatient endocrine follow up.

Discussion: Bilateral adrenal haemorrhages have been reported in patients with infection, trauma and anticoagulants ^[3]. Due to very high mortality rate, it is important to have a very high index of suspicion for treatment. IV steroids are the key if there is a suspicion of adrenal insufficiency in patients. In this case the aetiology of bilateral adrenal haemorrhage is likely multifactorial, including postpartum haemorrhage and sepsis. It is also important to distinguish in such cases whether the adrenal insufficiency is not due to central cause as postpartum haemorrhages was also noted. In this case the anterior Pituitary hormones were normal, and ACTH was raised.

Reference: 1-Arlt W, Allolio B. Adrenal insufficiency. Lancet. 2003;361:1881–93.

2-Fatima Z, Tariq U, Khan A, Sohail MS, Sheikh AB, Bhatti SI, et al. A rare case of bilateral adrenal hemorrhage. Cureus. 2018;10:e2830.

3- Ketha S, Smithedajkul P, Vella A, Pruthi R, Wysokinski W, McBane R. Adrenal haemorrhage due to heparin-induced thrombocytopenia. Thromb Haemost. 2013;109:669–75.