: We report on 4 patients who acutely presented to our unit and diagnosed with adrenal haemorrhage.
Case 1: A 72 year old man presented with generalised abdominal pain, fever and raised CRP a week after hip replacement surgery. CT abdomen showed non-enhancing bilateral adrenal lesions consistent with adrenal haemorrhage. He was taking Apixaban for DVT following hip replacement. SST was performed which confirmed suboptimal cortisol response. Hence, Treated as Adrenal insufficiency secondary to Waterhouse Friedrichsen syndrome.
Case 2: A 63 man has hypertension presented with acute severe left flank pain. CT renal and CT angiogram showed a large left adrenal and perinephric haemorrhage. This was treated with coil embolization of the left suprarenal artery. Initial biochemistry showed mildly raised plasma normetanephines which subsequently normalised. ONDST and aldosterone/plasma renin activity were normal. Serial CT scan showed gradual resolution of the adrenal haemorrhage with no underlying adrenal lesion.
Case 3: A 56 year old man presented with a 3 day history of epigastric and left sided abdominal pain with nausea and fever. CT scan of the abdomen revealed a 5 cm adrenal haemorrhage which was contained within the gland. Adrenal biochemistry were normal. Serial scans showed resolution of the adrenal haemorrhage and a residual adrenal nodule.
Case 4: A 19 year old primigravida, 35 weeks gestation, presented with acute severe right flank pain and vomiting. MRCP was performed. This revealed a right adrenal gland haemorrhage. Adrenal biochemistry were normal. She was delivered by Caesarian Section at term with 100 mg IV hydrocortisone cover and with no complications to either mother or baby. CT adrenals performed 8 weeks postpartum was entirely normal with no evidence of residual haemorrhage or adrenal mass.
Conclusion: We report on 4 patients who were found to have unilateral or bilateral adrenal haemorrhage. The common presenting symptom was abdominal pain. Adrenal function was essentially normal in all patients apart from the patient with bilateral adrenal haemorrhage (case 1) who had adrenal insufficiency secondary to Waterhouse Friedrichsen Syndrome. In last 3 cases adrenal haemorrhage resolved or decreased in size on subsequent scans. Anticoagulants were being used in one patient otherwise no risk factors identified in the remaining cases. One patient required coil embolization to stop the bleeding. Adrenal haemorrhage though rare, should be included in the differential diagnosis of acute abdominal pain as if missed diagnosed could be complicated with life threatening adrenal insufficiency.