MON-351 Bilateral Adrenal Haemorrhage Secondary to Intra-Abdominal Sepsis: A Case Report

Introduction Adrenal failure secondary to bilateral haemorrhage is a rare presentation with a significantly high mortality rate. Sepsis, caused by a deregulated inflammatory response to infection, can result in bilateral adrenal haemorrhage particularly with predisposing factors such as major surgery and anticoagulation. Clinical Case A 58-year-old white man presented to the emergency department with a two-week history of diarrhoea and vomiting. On examination, the abdomen was tender over the right lower quadrant with guarding. An abdominal CT confirmed diverticulitis with small bowel perforation. Patient deteriorated with conservative management, and a repeat abdominal CT showed worsening colonic inflammation with new pelvic collection suggesting of intra-abdominal sepsis. The patient underwent urgent laparotomy for Hartman’s procedure. However, he did not improve post-operatively, remaining hypotensive and febrile with elevated inflammatory markers despite continuous IV antibiotics. The working diagnosis remained as intra-abdominal sepsis. He had a series of abdominal CT scans at different intervals, and on the 4th scan, a new bilateral adrenal enlargement consistent with haemorrhage/infarction was identified. However, an unreported early haemorrhagic transformation is visible on the previous scan from ten days earlier. A random Cortisol was 157nmol/L (200-650nmol/L-morning peak) which appeared low for critical illness. Serum Aldosterone was 206pml/L (61-980pmol/L) and Aldosterone/Renin ratio was 12.6 (<70). The patient was treated with intravenous hydrocortisone with excellent response and later discharged on oral hydrocortisone. He remains well with stable blood pressure. A repeat adrenal CT, five months post discharge show normal adrenal glands. He is due for an ATCH stimulation test prior to weaning of oral steroids. Conclusion This case describes a potentially life-threatening complication of bilateral adrenal haemorrhage following intra-abdominal sepsis and surgery. It highlights the importance of screening for adrenal insufficiency with close attention to adrenal anatomy on imaging, for patients who remain in shock despite treatment for sepsis.