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adrenal hemorrhage

Etiology: - contributing factors - adrenocorticotropic hormone (ACTH) - stress increases ACTH secretion which stimulates adrenal arterial blood flow - normally limited venous drainage of the adrenal may be exceeded by increased arterial blood flow - adrenal vein spasm & thrombosis may contribute - associated disorders - sepsis (3%) [4] more common with bilateral adrenal hemorrhage due to - Neisseria meningitidis (most common) - Pseudomonas - Streptococcus pneumoniae - group A beta-hemolytic streptococci - Neisseria gonorrhoeae - Escherichia coli - Klebsiella pneumoniae - Haemophilus influenzae (group B) - Salmonella choleraesuis - Pasteurella multocida - Acinetobacter calcoaceticus - Plesiomonas shigelloides - hemorrhagic diatheses (11%) [4] - thrombocytopenia - heparin-induced thrombocytopenia - anticoagulation - vitamin K deficiency - anti-platelet therapy - thromboembolic disorders, coagulopathy (6%) [4] - more common with bilateral adrenal hemorrhage [4] - antiphospholipid antibody syndrome (most common) - disseminated intravascular coagulation (DIC) - deep vein thrombosis - peripheral arterial embolism - pulmonary embolism - ischemic stroke - congestive heart failure - myocardial infarction - inflammatory bowel disease - acute pancreatitis - hepatic cirrhosis - granulomatous disease - amyloidosis - adrenal neoplasm (6%) [4] - metastatic cancer (most common neoplasm) [4] - lung cancer - gastric cancer - obstetric causes - pre-eclampsia - spontaneous abortion - antepartum or postpartum hemorrhage - twisted ovarian cyst - surgical procedures (41%) [4] - liver transplantation (most common) [4] - CABG - hip replacement - intracranial surgery - hepatic arterial chemoembolization - unilateral adrenal hemorrhage (93%) - blunt trauma (30%) - motor vehicle accident most common [4] - neurofibromatosis - long-term NSAID use - pregnancy Epidemiology: - reported in 0.2-1.8% of autopsies - may be present in 15% of patients who die of shock - male:female ratio 2:1 Pathology: - unilateral adrenal gland involvement (93%) - extensive necrosis of all 3 adrenal cortical layers & of medullary adrenal cells - retrograde migration of medullary cells into the zona fasciculata - widespread hemorrhage into the adrenal gland that may extend into the perirenal fat - adrenal vein thrombosis Clinical manifestations: - incidental presentation (41%) - post traumatic presentation (28%) - presentation with pain (25%) - abdominal pain - low back pain - pelvic pain - thoracic pain - more common with bilateral adrenal hemorrhage [4] - critical illness more common with bilateral adrenal hemorrhage [4] - symptoms of acute adrenal insufficiency - more common with bilateral adrenal hemorrhage [4] - fatigue, weakness, dizziness - anorexia - nausea/vomiting - diarrhea - myalgias - fever (50-70%) - tachycardia (40-50%) - orthostatic hypotension (20%) - skin hyperpigmentation (rare) - rash (75% of patients with Waterhouse-Friderichsen syndrome) - small, pink macules or papules, rapidly followed by petechial lesions, which gradually transform into large, purpuric, coalescent plaques in late stages - signs of acute abdomen, including guarding, rigidity, or rebound tenderness (15-20%) - - more common with bilateral adrenal hemorrhage [4] - confusion & disorientation (20-40%) - may be asymptomatic (rare) Laboratory: - complete blood count (CBC) with differential - anemia - leukocytosis - eosinophilia - comprehensive metabolic panel - serum sodium: hyponatremia - serum potassium: hyperkalemia* - serum creatinine, serum urea nitrogen: prerenal azotemia - hyponatremia, hyperkalemia, & prerenal azotemia are present in ~50% of patients with extensive, bilateral adrenal hemorrhage - serum calcium: mild hypercalcemia may rarely occur - serum glucose: hypoglycemia may occur, but is rarely severe - serum cortisol, plasma ACTH, serum aldosterone - plasma renin activity (PRA) - Cortrosyn stimulation test confirms the diagnosis of adrenal insufficiency * contrast with pituitary apoplexy: no hyperkalemia Special laboratory: - ultrasound of the adrenals (including Doppler) - reveals hyperechoic masses that contain a central echogenic area in the adrenal glands - several weeks after the acute event, the central echogenicity decreases as the hematomas become cystic. - percutaneous biopsy is helpful in establishing metastatic disease Radiology: - computed tomography (CT) - magnetic resonance imaging (MRI) Complications: - adrenal crisis (bilateral adrenal hemorrhage) - unilateral adrenal hemorrhage is not associated with acute adrenal insufficiency - shock - death (rare) [4] Management: - see adrenal insuffciency - acute medical therapy - correct fluid, electrolyte, & red cell mass deficits - treat adrenal insufficiency - rarely needed for unilateral adrenal hemorrhage [4] - hydocortisone - adult: - 10-12 mg/m2/d PO divided BID for maintenance; 10-20 mg upon awakening; 5-10 mg in early afternoon - 50-100 mg IV TID for severe stress pediatric - 10-12 mg/m2/d PO divided TID for maintenance - 80-100 mg/m2/d IV under conditions of stress - surgery - adrenalectomy (open or laparoscopic) - nontraumatic adrenal hemorrhage - generally not necessary except in patients with - primary adrenal tumors - extensive retroperitoneal hemorrhage (rare) - traumatic adrenal hemorrhage - treatment of associated injuries - exploration of penetrating wounds - control of bleeding - consultations - endocrinology - interventional radiology - urology or surgery - others as needed - chronic adrenal insufficiency - long-term glucocorticoid replacement - need for mineralocorticoid replacement is variable - androgen replacement therapy may be beneficial in women - prognosis: - chronic adrenal insufficiency occurs in most patients who survive extensive, bilateral adrenal hemorrhage, - rare case reports exist of patients who had complete recovery of adrenal function after an episode of extensive, bilateral adrenal hemorrhage & acute adrenal insufficiency

Specific

Waterhouse-Friderichsen syndrome

General

internal hemorrhage adrenal gland disease

References

  1. Tritos NA eMedicine: Adrenal Hemorrhage http://emedicine.medscape.com/article/126806-overview
  2. Rosenberger LH, Smith PW, Sawyer RG et al Bilateral adrenal hemorrhage: the unrecognized cause of hemodynamic collapse associated with heparin-induced thrombocytopenia. Crit Care Med. 2011 Apr;39(4):833-8. Review. PMID: 21242799 Free PMC Article
  3. Medical Knowledge Self Assessment Program (MKSAP) 17, 18. American College of Physicians, Philadelphia 2015, 2018.
  4. Dogra P et al. Adrenal hemorrhage: A comprehensive analysis of a heterogeneous entity-etiology, presentation, management, and outcomes. Mayo Clin Proc 2024 Mar; 99:375. PMID: 38432745 PMCID: PMC10917120 (available on 2025-03-01) https://www.mayoclinicproceedings.org/article/S0025-6196(23)00474-3/abstract