Endocrine Abstracts

Case history: We present the case of a 73 year old lady who was admitted following a neck of femur fracture after a fall. She had surgery performed with no major complications. During her inpatient stay, she unexpectedly became very unwell, complaining of abdominal pain, low grade pyrexia, tachycardia, tachypnoea, hypotension, nausea and vomiting (1). Initial management was as sepsis of unknown source.

Investigations: Bloods on admission (23/08/23): Hb 132 g/l, MCV 95.7 fl, Plt 219 10×9/l, WCC 11 10×9/l, Na 135 mmol/l, potassium 3.8 mmol/l, eGFR ml.min/1.73 m², LFTs normal, CRP 3, TSH 2.06. Bloods (31/08/23): Hb 104 g/l, MCV 94.4 fl, Plt: 38 10×9/l, WCC 12.3 10×9/l, neutrophils 9.7 10×9/l, lymphocytes 1.2 10×9/l, Na 125 mmol/l, potassium 3.3 mmol/l, eGFR>90, LFTs normal, albumin 28, CRP 226 mg/l; SST (November 2023): baseline cortisol: 15 nmol/l; 30 min: 109 nmol/l. US abdomen (30/08/23) was normal CT abdomen and pelvis (03/09/2023): bilateral adrenal haemorrhage (BAH) and partial left renal vein thrombosis; subcutaneous haematoma associated with left THR. CTPA (03/09/23): bilateral segmental and subsegmental emboli with segmental infarct in RLL.

Conclusion and discussions: Our patient had BAH secondary to HIT (heparin induced thrombocytopenia). Platelets dropped 8 days later after she was started on dalteparin and her HIT screening came back positive. We discuss a rare but serious presentation of adrenal crisis which can be potentially fatal, if clinical suspicion is not high, and non-infective causes of shock are not considered. This is very relevant post-surgery, after anti-coagulant use and any major trauma. Therefore, it is essential that it is considered as a differential particularly by specialities not used to managing hypoadrenalism. Radiologically findings can often be difficult and need expertise in abdominal radiology as often represent a mass and can be mistaken as adrenal neoplasm(3). There are two proposed mechanisms involved in the pathogenesis of idiopathic haemorrhages (2) stress and adrenal medullary venous thrombosis. Other causes of adrenal haemorrhage in pheochromocytoma, metastatic lesions and adrenocortical carcinoma, which then will need to be investigated involving adrenal MDT with endocrinologist.

Index references: 1) Simon DR, Palese MA. Clinical update on the management of adrenal hemorrhage. Curr Urol Rep. 2009;10:78–83.

2) Acute spontaneous unilateral adrenal haemorrhage: etiology and imaging findings in six cases – PMC (nih.gov).

3) Huelsen-Katz AM, Schouten BJ, Jardine DL, et al. Pictorial evolution of bilateral adrenal haemorrhage. Intern Med J. 2010;40:87–88.