Endocrine Abstracts

Background: Unilateral adrenal haemorrhage is usually asymptomatic and picked up incidentally on CT imaging. However, adrenal haemorrhage can cause flank pain and when bilateral, adrenal insufficiency or adrenal crisis. Biochemical changes include electrolyte imbalances, low platelet count and anaemia. We report a case of unilateral adrenal haemorrhage with devastating outcome.

Case: A 45-year-old male smoker was incidentally found to have a rapidly growing left adrenal mass, reported as adrenal haemorrhage. Initial CT imaging for respiratory symptoms showed right upper lobe and hilar lymphadenopathy, but subsequent mediastinoscopy and biopsy revealed only reactive changes. At this stage he had normal sized adrenal glands with preserved tri-cornuate architecture. On interval scanning 4 months later, he was first noted to have a heterogeneous, spherical, 3cm enlargement of his left adrenal reported as adrenal haemorrhage, along with resolution of the hilar lymphadenopathy. However, further scanning over the next 8 weeks showed progressive enlargement of a heterogeneously enhancing left adrenal mass from 3cm to 5.5cm then 9cm. An MDT decision for open adrenalectomy was made. At operation, 10 days later, the lesion was 12cm and adherent to the left kidney and posterior peritoneum, with multiple neovascularisations. Histology showed a poorly differentiated oncocytic tumour, Ki-67 index 60% with epithelial staining (AE1-3) but no more specific features. Post-operatively, he continued to lose weight and re-presented 10 days later with right upper quadrant and back pain. Repeat imaging showed metastatic collapse of the L5 vertebral body and multiple liver, right adrenal, bone, skin, and lung metastases. He was commenced on carboplatin and etoposide chemotherapy but died a few weeks later.

Discussion: Around 20% of adrenal haemorrhages are due to adrenal tumours and serial imaging should be performed to ensure that there is not progressive enlargement before the radiological diagnosis can be accepted.