Adrenal haemorrhage is a relatively rare phenomenon which can often present non-specifically. In the case of bilateral haemorrhages, if unrecognised the endocrine sequelae may prove to be fatal. These three cases highlight very different clinical presentations of this important condition.
Case 1: A 74-year-old male was admitted following a fall and fractured neck of femur. His post-operative recovery was complicated by acute myocardial infarction, pneumonia, bilateral pulmonary emboli, and heparin induced thrombocytopenia. On ITU he was noted to have labile blood pressures, with systolic readings ranging from <100 to >200 mmHg. A CT aorta had been reported as showing bilateral adrenal masses (possible myelolipomas), whilst a short Synacthen test confirmed hypocortisolaemia. Re-review of his CT aorta highlighted these were not adrenal masses but in fact represented sub-acute bilateral adrenal haemorrhages. His blood pressure and clinical conditioned stabilised with hydrocortisone and fludrocortisone cover.
Case 2: A 49-year-old male was admitted with sudden onset severe right upper quadrant pain radiating to the back. Arterial blood gas analysis revealed a raised lactate of three; Blood tests were only remarkable for a macrocytosis and raised white cell count of 17.3×109/l. A CT aorta confirmed acute bilateral adrenal haemorrhages with extension into the retroperitoneum. His short Synacthen test was normal. Of note, a previous CT also highlighted lucencies within the pelvis believed to represent fibrous dysplasia and bilaterally enlarged nodular adrenal glands; He awaits screening for GNAS1 mutation.
Case 3: A 66-year-old female was referred to the endocrine clinic after an ultrasound for abnormal liver function tests detected an incidental right supra-renal mass. MRI confirmed a 3.7×2.8 cm lesion in the right adrenal gland. Endocrine testing was normal. A subsequent CT for further characterisation showed peripheral calcification and lack of enhancement. Multi-disciplinary team review suggested that this most likely represents adrenal haemorrhage.