We report a rare case of 37 years female of Greek and Irish extraction with a history of thalassemia trait, who presented with generalised weakness and severe loin and pelvic pain 9 days post vaginal hysterectomy and 3 days after hospital discharge. After readmission, she developed mild pyrexia (37.5°C), hypotension, mild hyponatraemia with plasma sodium which fell from 138 to 131 mM and early signs of acute respiratory distress syndrome. A Short Synacthen test was performed and the patient was empirically commenced on stress dose of intravenous hydrocortisone.
CT scan of abdomen and pelvis revealed pelvic haematoma and bilateral adrenal haemorrhage. The infected haematoma was surgically drained and the patient was treated empirically with meropenem and gentamicin and later on with linezolid. Blood and pelvic haematoma culture failed to grow any organisms. Baseline plasma cortisol was 89 nM and 30 min post tetracosarin was 92 nM confirming adrenal insufficiency. The patient made a full recovery and was discharged on maintenance oral hydrocortisone.
The diagnosis of adrenal insufficiency in patients with bilateral adrenal haemorrhage is challenging and requires clinical suspicion due to the subtle nature of its presentation, and has previously been well documented as a post-mortem diagnosis. The combination of hypotension, hyponatraemia and generalised lethargy should lead to empirical glucocorticoid treatment until confirmation of adrenal insufficiency is made by hormonal evaluation.
Adrenal haemorrhage is a frequently fatal condition but if diagnosed, may be successfully treated. It may develop without predisposing conditions but more often occurs in patients subjected to severe stress such was in the described case. This rare case illustrates the importance of rapid onset hyponatraemia and unexplained hypotension as markers of acute adrenal insufficiency.
25 - 29 Apr 2009
European Society of Endocrinology