Nontraumatic adrenal hemorrhage: the adrenal stress

Abstract

Bilateral adrenal hemorrhage is a rare condition, which is burdened by potentially life-threatening consequences related to the development of acute adrenal insufficiency. Despite treatment with stress-dose glucocorticoids, a mortality rate of 15% has been reported, which varies according to the severity of underlying predisposing illness and could be much more higher if the adrenal insufficiency is not promptly recognized. An early diagnosis is crucial, though, because of nonspecific clinical and laboratory findings, adrenal hemorrhage is rarely suspected. Therefore, imaging has a pivotal role for the diagnosis of this uncommon condition but, despite adrenal hematomas characteristically appear round or oval with peripheral fat stranding, their initial presentation could be ambiguous. The authors describe a case of postoperative bilateral adrenal hemorrhage initially presenting at computed tomography scan as thickening of both glands surrounded by fat stranding, which led to close monitoring of adrenal function before unequivocal hemorrhage developed.

Case Report: COVID-19 with Bilateral Adrenal Hemorrhage

“…The importance of this entity relies on its potentially fatal consequences, with a mortality rate of 15% even after treatment. 2 Traumatic BAH is extremely rare. The most frequent causes are surgery (including unrelated procedures), severe illness, trauma, severe sepsis (e.g., Waterhouse-Friedrichsen syndrome associated with meningococcal septicaemia), hypercoagulable states (including antiphospholipid antibody syndrome), burns, and anticoagulant treatment.…”

“…Adrenal glands receive vascularization from three adrenal arteries from the aorta, the inferior phrenic artery, and the renal artery; this results in multiple arterioles forming a vascular plexus. 2 , 5 However, the adrenal gland is drained exclusively by the central adrenal vein, producing a point that is more vulnerable in the event that there is venous vasoconstriction during shock, which can lead to an overload of these collecting capillaries. An excessive increase in blood pressure or a thrombotic event at the level of the adrenal vein could cause a bleed.…”

A Rare Case of Bilateral Adrenal Hemorrhage

“…The preferred treatment for BAH is intravenous hydrocortisone (100 mg bolus, followed by 200 mg per day via continuous intravenous infusion) and fluid resuscitation with normal saline. Despite treatment, the mortality rate of BAH is as high as 15%, which could be higher if there is a delay in diagnosis and subsequent initiation of the recommended treatment [ 11 - 12 ].…”

Spontaneous adrenal hematoma in pregnancy

“…The high-risk factors of increased arterial blood supply to adrenal gland with limited venous drainage, physiological adrenal cortex hyperplasia, and hypercoagulative status during pregnancy may cause hemorrhage when there are no related factors in inducing bleeding such as recent surgery, coagulopathy, trauma, or underlying adrenal mass. [1–3]…”

“…Until now, the main therapeutic methods are surgical resection and expectant management, which depend on the patient's condition and the situation of the hematoma. [1–3] While the accurate diagnosis and risk assessment of the hematoma may play an important role in this process. In this article, we present a rare case of unilateral spontaneous adrenal hematoma in a pregnant woman, aiming to share this experience and summarize the signal characteristics of simple adrenal hematoma in magnetic resonance imaging (MRI).…”