Non-Hemorrhagic Adrenal Infarction during Pregnancy: The Diagnostic Imaging Keys

Abstract

Background: non-hemorrhagic adrenal infarction (NHAI) is a rare cause of acute abdominal/flank pain during pregnancy; in order to ensure prompt and appropriate treatment, this diagnosis should not be overlooked. This case series highlights pertinent imaging findings, including ultrasounds (USs), computed tomography (CT), and magnetic resonance imaging (MRI) of recent NHAI cases. Methods: we compiled all consecutive NHAI cases from two university hospitals over a two-year period and checked the relevant clinical, laboratory, and imaging findings. Relevant articles on NHAI published from January 2010 to March 2021 were analyzed. Results: six cases were found in our database. CT-scans typically showed enlarged, hypodense, and non-enhanced adrenal glands. Unenhanced MRIs allowed for diagnoses and showed enlarged adrenal glands in the signal hyperintensity on T2 and diffusion-weighted imaging, without any signal hyperintensity on T1. In two of our six cases, USs showed swollen adrenal glands with fluid collection. Conclusion: NHAI and its differential diagnosis—in cases of acute pain during pregnancy—highlight the crucial roles of integrated radiological examination and cooperation between obstetricians and radiologists, both of whom should consider the location of the pain, the accessibility and tolerance of MRI, and the radiation exposure of CT. Despite its supposed poor sensitivity, an US performed because the patient reports pain should also be used to examine the adrenal gland regions. Non-enhanced MRI is clearly of value and access to it in emergencies is important to avoid radiation exposure

Recurrent bilateral adrenal infarction with myelodysplastic/myeloproliferative neoplasm-unclassifiable (MDS/MPN-U): a case report

“…There are some case reports in which anticoagulants were administered in accordance with the underlying diseases or conditions, although there is no evidence-based treatment for adrenal infarction itself. Heparin, for example, was administered in cases of adrenal infarction with APS [ 2 , 3 ] or pregnancy [ 5 , 7 , 8 ], and warfarin was administered in a case of COVID-19 [ 11 ]. Attention should be paid to the consequent adrenal hemorrhage [ 3 , 22 ] once anticoagulation therapy is initiated.…”

“…Bilateral adrenal infarction caused by venous adrenal gland thrombosis is rare [ 1 ]. The underlying diseases or conditions known to trigger adrenal infarction include antiphospholipid antibody syndrome (APS) [ 2 – 4 ], pregnancy [ 5 – 8 ], coronavirus disease 2019 (COVID-19) [ 9 – 11 ], and other thrombophilia or a hypercoagulable state. Adrenal infarction typically provokes backache and/or stomachache.…”

Acute abdominal pain due to atypical bilateral adrenal infarction in acute myeloid leukemia with alterations related to myelodysplasia: A case report

“…The present report describes an uncommon case of acute abdomen following adrenal infarction caused by AML. Although adrenal diseases such as adrenal crisis and adrenal infarction can cause acute abdomen manifesting as acute back, chest, and upper abdominal pain, 4,8,10,11 such cases are rare in actual clinical practice. Previous studies regarding abdominal pain showed several cases of adrenal disease 7,12,13 .…”

“…Although hematologic diseases can cause adrenal infarction, acute myeloid leukemia (AML) rarely causes acute abdominal pain with adrenal infarction 3 . In addition, in most cases of adrenal infarction, computed tomography (CT) images reveal diffuse enlargement of the adrenal glands 4,5 . Adrenal enlargement is mainly caused by adenoma, adrenal cortical hyperplasia, and metastatic infiltration 6 .…”

New-onset primary adrenal insufficiency in pregnancy associated with a unilateral adrenal infarction: a case report

“…MRI features of NHAI include unilateral adrenal enlargement, increased T2 signal intensity without T1 hyperintensity and retroperitoneal edema near the affected adrenal gland. CT findings of NHAI consist of enlargement and hypoenhancement of the adrenal gland ( 17 ). Urinary tract calculi should be considered in the differential diagnosis for acute flank pain in pregnancy.…”