Approach to the Patient With Adrenal Hemorrhage

Abstract

Adrenal hemorrhage is an uncommon, underrecognized condition that can be encountered in several clinical contexts. Diagnosing adrenal hemorrhage is challenging due to its nonspecific clinical features. Therefore, it remains a diagnosis that is made serendipitously on imaging of acutely unwell patients rather than with prospective clinical suspicion. Adrenal hemorrhage can follow abdominal trauma or appear on a background of predisposing conditions such as adrenal tumors, sepsis, or coagulopathy. Adrenal hemorrhage is also increasingly reported in patients with COVID-19 infection and in the context of vaccine-induced immune thrombocytopenia and thrombosis. Unexplained abdominal pain with hemodynamic instability in a patient with a predisposing condition should alert the physician to the possibility of adrenal hemorrhage. Bilateral adrenal hemorrhage can lead to adrenal insufficiency and potentially fatal adrenal crisis without timely recognition and treatment. In this article, we highlight the clinical circumstances that are associated with higher risk of adrenal hemorrhage, encouraging clinicians to prospectively consider the diagnosis, and we share a diagnostic and management strategy.

Keywords: COVID-19; adrenal apoplexy; adrenal crisis; adrenal incidentaloma; adrenal insufficiency; antiphospholipid syndrome.

Figure 1.

Representative scans for Case 1. A, CT scan undertaken 2 months prior to the detection of adrenal hemorrhage. The arrows point to normal appearing adrenal glands. B, CT scan showing the acute development of bilateral adrenal masses with surrounding soft tissue stranding consistent with bilateral adrenal hemorrhage. C, 3-month interval CT scan showing marked reduction in the size of the adrenal hematomas. D, 9-month interval CT scan showing resolution of hematomas and atrophied adrenal glands.

Figure 2.

Representative scans for Case 2. A, CT scan at time of diagnosis showing a large, indeterminate left adrenal mass. B, 3-month interval MRI scan showing a reduction in size of the adrenal mass suggestive of hemorrhage. Adrenal mass is hypointense on T1 (left) with mixed intensity on T2 (right) weighted images. C, Color flow Doppler ultrasound, undertaken due to the MRI T2 mixed intensity, showing a nonvascular well-defined round lesion, consistent with adrenal hematoma. D, 6-month interval MRI showing a further reduction in size of the T1 hypointense adrenal mass with peripheral contrast enhancement suggestive of an underlying adrenal tumor with resolution of the hemorrhagic component.

Figure 3.

Depiction of the pathophysiological mechanism that precipitate adrenal hemorrhage. Abbreviation: ACTH, adrenocorticotropic hormone.

Figure 4.

A flow diagram outlining a recommended approach to the patient with adrenal hemorrhage. *Adrenal insufficiency is unusual in unilateral adrenal hemorrhage but has very rarely been reported and it should be strongly considered if the contralateral adrenal gland appears infarcted/atrophic on imaging. **Hydrocortisone also provides mineralocorticoid activity, with 40 mg of hydrocortisone equivalent to 100 μg of fludrocortisone. Prednisolone has some mineralocorticoid activity, while dexamethasone has none (79).