A 72-year-old man, otherwise fit and well, with treated hypertension presented to our hospital with abdominal pain and vomiting. He was febrile with deranged liver function tests and elevated inflammatory markers. Abdominal ultrasound showed a right suprarenal mass, and a normal gallbladder.
CT confirmed a 37×31×24 mm right adrenal mass with no significant contrast enhancement, and bilateral pneumonia responsible for the septic picture. Thrombus was noted in the left external iliac artery for which he was anticoagulated. Three days later, following appropriate antibiotic therapy, his pain worsened and repeat CT showed inflammatory stranding around the right adrenal mass and new nodularity due to acute adrenal haemorrhage. Further investigations showed no measurable malignancy and his urinary catecholamine collection was normal. He was referred for an adrenalectomy, however as his pre-operative CT showed the mass was no longer evident, adrenalectomy was not performed. The adrenal gland is particularly vulnerable to haemorrhage. Under stress, there in an increase in arterial blood supply to the glands. As it as only one or two veins, this makes it susceptible to venous thrombosis and increased venous pressure, which can then result in haemorrhage.
Adrenal haemorrhage has several aetiologies. It is commonly associated with meningococcal sepsis, classically known as the WaterhouseFriderichsen syndrome. It occurs less commonly in the context of sepsis from other pathogens which lead to disseminated intravascular coagulation, as a result of trauma, anticoagulant therapy, and may be spontaneous.
Radiologically, the adrenal glands may calcify following haemorrhage, or as in this case may no longer be visible. In our case, blood cultures were not particularly helpful in identifying an organism. However it is likely that he suffered an adrenal haemorrhage in the context of severe sepsis due to pneumonia, with the added risk factor of anticoagulant treatment.