Severe bilateral adrenal hemorrhages in a newborn complicated by persistent adrenal insufficiency

Abstract

SummaryBilateral adrenal hemorrhages rarely occur during the neonatal period and are often associated with traumatic vaginal deliveries. However, the adrenal gland has highly regenerative capabilities and adrenal insufficiency typically resolves over time. We evaluated a newborn female after experiencing fetal macrosomia and a traumatic vaginal delivery. She developed acidosis and acute renal injury. Large adrenal hemorrhages were noted bilaterally on ultrasound, and she was diagnosed with adrenal insufficiency based on characteristic electrolyte changes and a low cortisol (4.2 µg/dL). On follow-up testing, this patient was unable to be weaned off of hydrocortisone or fludrocortisone despite resolution of hemorrhages on ultrasound. Providers should consider bilateral adrenal hemorrhage when evaluating critically ill neonates after a traumatic delivery. In extreme cases, this may be a persistent process.Learning points:Risk factors for adrenal hemorrhage include fetal macrosomia, traumatic vaginal delivery and critical acidemia.Signs of adrenal hemorrhage include jaundice, flank mass, skin discoloration or scrotal hematoma.Adrenal insufficiency often is a transient process when related to adrenal hemorrhage.Severe adrenal hemorrhages can occur in the absence of symptoms.Though rare, persistent adrenal insufficiency may occur in extremely severe cases of bilateral adrenal hemorrhage.Consider adrenal hemorrhage when evaluating a neonate for shock in the absence of an infectious etiology.

Bilateral Adrenal Hemorrhage in a 6-Day-Old Neonate Presenting with Hematuria of 2 Days Duration: Case Report

“…Additional risk factors include bleeding disorders, anticoagulant administration, and child abuse. 2,4 In our case, the possible identified risk factors were macrosomia and difficult delivery. In neonates with adrenal hemorrhage, the kidneys could be involved in several ways, one of which is vascular obstruction due to an extension of thrombosis in the adrenal vein into the renal vein, or a retrograde spread of thrombosis from the inferior adrenal artery into the renal artery which could in turn lead to different renal symptoms including hematuria.…”

“…Adrenal hemorrhage is the most common cause of adrenal mass in neonates, 10% of the cases occurring bilaterally. 2,3 Our case was among the few cases of bilateral adrenal hemorrhage.…”

“… 3 Additionally, anemia, unexplained jaundice, hematuria, or scrotal hematoma or swelling may be the presenting sign. 2 , 4 , 6 Laboratory findings include anemia, hyponatremia, hyperkalemia, hypoglycemia, hypocortisolemia, eosinophilia, leukocytosis, hematuria, proteinuria, elevated adrenocorticotropic hormone, and elevated renin activity. 2 , 4 In our case, apart from hematuria, there was no other symptom.…”

“…2,4,6 Laboratory findings include anemia, hyponatremia, hyperkalemia, hypoglycemia, hypocortisolemia, eosinophilia, leukocytosis, hematuria, proteinuria, elevated adrenocorticotropic hormone, and elevated renin activity. 2,4 In our case, apart from hematuria, there was no other symptom. Initial diagnosis of an adrenal mass in a neonate is usually made by ultrasound whereas CT and MRI are helpful to rule out other possible differential diagnoses like congenital neuroblastoma, Wilm's tumor, hydronephrosis, cystic renal disease, and vascular thrombosis.…”

“…1 Adrenal hemorrhage is commonly seen in male neonates; 90% of the cases are unilateral and 75% of the cases occur on the right side. 2 Since the right adrenal vein drains directly into the inferior vena cava, compression of the right adrenal gland between the liver and the spine induces venous pressure changes and hence increases the risk of hemorrhage. 1 We hereby report a 6-day-old male neonate with bilateral adrenal hemorrhage who presented with hematuria.…”