Background: Acute adrenal insufficiency is a life threatening condition. Signs and symptoms are often non-specific. The adrenal gland has the richest arterial supply of any tissue with limited venous drainage and this mismatch predisposes to haemorrhagic infarction. We present a case report of acute adrenal insufficiency due to bilateral adrenal haemorrhagic infarcts associated with an open ankle fracture.
Case history: A 52-year man fell from a ladder sustaining an open fracture of his right ankle. On presentation to A&E the wound was dressed and the fracture stabilised. X-ray revealed comminuted fractures of the distal shaft of the fibula and the distal tibia. Intravenous antibiotics and prophylactic LMW heparin were administered and baseline U&Es normal. Seventy-two hours into the admission he was taken to theatre, the wound debrided and the fibula # pinned. Anaesthetic records record some hypotension during the procedure with SBP dipping to 60 mmHg. During the subsequent days recurrent pyrexia and hypotension were noted and antibiotics continued. His Na gradually fell with a nadir at day 9 of 122 mmol/l. This responded to intravenous therapy and at a 2nd operation on day 13 the tibial # was pinned. Serum Na was again noted to fall over the next few days with a nadir of 124 mmol/l on day 23. The patient complained of intermittent abdominal pain and began hallucinating on day 20. Enterobacter cloacae was cultured from the wound. Serum cortisol was measured on days 23 and 24 being undetectable on both occasions. His platelets had dropped to 56. A diagnosis of acute adrenal insufficiency was made and high dose intravenous hydrocortisone administered. Clinical improvement was evident within 48 h. Baseline pituitary tests were unremarkable. CT scans showed enlarged heterogeneous adrenal glands consistent with bilateral haemorrhagic infarction.
Conclusion: Acute adrenal insufficiency due to bilateral adrenal haemorrhagic infarction is a rare event that can have catastrophic consequences if not diagnosed and treated in a timely manner. Our patient presented with a common orthopaedic injury and an inpatient course characterised by pyrexia, low BP and hyponatraemia, in themselves unremarkable and frequently associated with trauma/sepsis. A high index of suspicion in a context of slow deterioration lead to further investigation and the additional diagnosis being made.