Bilateral Adrenal Hemorrhage with Subsequent Resolution of Adrenal Insufficiency

Introduction:
Bilateral adrenal hemorrhage (BAH) is a rare cause of adrenal crisis with an incidence of 0.1 to 1%. It is a life-threatening emergency with 10-20% mortality rate due to the challenge of correctly diagnosing and promptly treating it. Clinical manifestations vary based on the size of the bleed and can mimic severe illness and sepsis. This case describes a rare case of BAH secondary to anticoagulant usage which precipitated adrenal crisis with resolution of adrenal insufficiency.

Case Description:
A 71-year-old male known to have hypertension, hyperlipidemia, type 2 diabetes mellitus, and atrial fibrillation on Xarelto presented with generalized weakness, chest pain and malaise. A week prior, he was evaluated for cholecystitis and a cholecystostomy tube was placed. Upon arrival, he was bradycardic and hypotensive. Labs were significant for hyperkalemia (6.0 mmol/L), hyponatremia (130 mmol/L), and a troponin elevation (12.2 ng/ml). He was started on heparin drip for NSTEMI and broad-spectrum antibiotics for presumed sepsis originating from previously known cholecystitis. CT scan (without contrast due to chronic kidney disease) showed bilat adrenal masses. The patient was transferred to ICU for both cardiac and sepsis monitoring.

Stress dose hydrocortisone (50 mg every 6 hours) was started for presumed adrenal insufficiency given the patient’s vital sign abnormalities and electrolyte derangements. CT scan images were re-evaluated with the radiologist and were consistent with BAH with greatest area of hemorrhage measuring 4cm on right. The patient was taken off of anticoagulation and started on a fludrocortisone 0.05mg daily. He had symptomatic improvement with both hydrocortisone and florinef treatment and was transitioned to a combined oral regimen prior to discharge. Potassium and sodium levels had normalized. On outpatient follow up he was weaned completely from steroids over one year with follow up 8 am cortisol 11 mcg/dL. We were not able to repeat the cortisol level nor complete an ACTH stimulation test due to follow-up challenges.

Discussion:
This case illustrates the importance of timely suspecting and treating adrenal insufficiency secondary to BAH due to high mortality risk. This patient did not have cortisol or ACTH levels confirming adrenal insufficiency due to the administration of steroids early in the hospital course. He did not have any adrenal related health problems despite subsequent admissions to the hospital. Recognition based on electrolyte abnormalities and presenting symptoms can be central to diagnosing adrenal crisis. In addition to the rare presentation of adrenal hemorrhage, this patient also demonstrated resolution of intrinsic adrenal function. There are a few case reports in the literature about partial recovery following hemorrhage however complete recovery is very rare.