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SAT-206 A Sweet and Salty Milieu: The Utility of CT in Bilateral Adrenal Hemorrhage

Introduction: Bilateral adrenal hemorrhage (BAH) is seldomly recognized as a cause of adrenal insufficiency due to nonspecific clinical manifestations within the milieu of major concurrent illnesses. CT abdomen is the investigation of choice to evaluate acute adrenal crisis. Clinical Case: A 68 year...

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Autores principales: Tavares, Matthew V, Sittol, Rani Delraj, Chang, Sang-Min, Otuonye, Gene, Barnes, Tanganyika
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Oxford University Press 2020
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7208497/
http://dx.doi.org/10.1210/jendso/bvaa046.807
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author Tavares, Matthew V
Sittol, Rani Delraj
Chang, Sang-Min
Otuonye, Gene
Barnes, Tanganyika
author_facet Tavares, Matthew V
Sittol, Rani Delraj
Chang, Sang-Min
Otuonye, Gene
Barnes, Tanganyika
author_sort Tavares, Matthew V
collection PubMed
description Introduction: Bilateral adrenal hemorrhage (BAH) is seldomly recognized as a cause of adrenal insufficiency due to nonspecific clinical manifestations within the milieu of major concurrent illnesses. CT abdomen is the investigation of choice to evaluate acute adrenal crisis. Clinical Case: A 68 year old female with systemic lupus erythematosus, anti-phospholipid antibody syndrome (APS) complicated by multiple strokes, on warfarin, and recent hip fracture presented with confusion, lethargy, fever, and cough. On exam she was febrile, tachycardic, tachypneic, disoriented with right sided hemiparesis, and crepitations on lung auscultation. Lab results were significant for leukocytosis of 14K/uL, hemoglobin (Hb) 9.9g/dL, INR 3.8, azotemia, normal electrolytes, and glucose 67mg/dL. Blood and urine cultures were negative. Anti-dsDNA, C3, and C4 were normal. CT chest showed right lower lobe infiltrates and bronchial debris. She was treated with antibiotics and bronchoscopy with mucus plug removal. Her lethargy and confusion persisted. MRI brain was negative for acute event. Hb fell to 7g/dL; managed conservatively with i.v. iron. CT abdomen showed BAH both measuring 3.5x3.5cm; AM cortisol was 5.5 mcg/dL. Warfarin was reversed with vitamin K; hydrocortisone 50mg q8h was started with improvement in her mental status. ACTH levels were <5pg/ml; ACTH stimulation testing was deferred as steroids were started emergently. Repeat CT showed stable BAH, AM cortisol increased to 19.4mcg/dL, and Hb stable at 8g/dL. She was discharged on hydrocortisone 10mg twice daily. Discussion: Trauma, corticotropin stimulation during stress, anticoagulation therapy, and APS inducing adrenal venous thrombosis have been identified as risk factors that predispose to BAH. There is a lack of consensus regarding normal cortisol levels in critical illness. Fluctuations in serum cortisol levels are frequent and not necessarily indicative of definite injury to the adrenal gland. CT abdomen, the investigation of choice in the acute setting, has a heterogeneous, high density appearance; the presence of an underlying adrenal mass cannot be excluded. BAH appears as diminished attenuation of the adrenal gland with respect to the adjacent tissues, along with thickening of the ipsilateral crura due to retroperitoneal extension of blood (1). MRI has a greater accuracy for identifying BAH in comparison to CT as it can discern adrenal hematoma from adjacent necrotic tissue and determine the acuity of the hematoma. Conclusion: The nonspecific clinical manifestations of BAH are frequently inseparable from those of the concurrent major illness. The diagnosis requires a high index of suspicion, initiation of prompt steroid replacement, and confirmation by CT abdomen. References: (1) Fatima, Z., Tariq, U., Khan, A., et. Al. A Rare Case of Bilateral Adrenal Hemorrhage. Cureus. 2018 Jun; 10(6): e2830. doi: 10.7759/cureus.2830
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spelling pubmed-72084972020-05-13 SAT-206 A Sweet and Salty Milieu: The Utility of CT in Bilateral Adrenal Hemorrhage Tavares, Matthew V Sittol, Rani Delraj Chang, Sang-Min Otuonye, Gene Barnes, Tanganyika J Endocr Soc Adrenal Introduction: Bilateral adrenal hemorrhage (BAH) is seldomly recognized as a cause of adrenal insufficiency due to nonspecific clinical manifestations within the milieu of major concurrent illnesses. CT abdomen is the investigation of choice to evaluate acute adrenal crisis. Clinical Case: A 68 year old female with systemic lupus erythematosus, anti-phospholipid antibody syndrome (APS) complicated by multiple strokes, on warfarin, and recent hip fracture presented with confusion, lethargy, fever, and cough. On exam she was febrile, tachycardic, tachypneic, disoriented with right sided hemiparesis, and crepitations on lung auscultation. Lab results were significant for leukocytosis of 14K/uL, hemoglobin (Hb) 9.9g/dL, INR 3.8, azotemia, normal electrolytes, and glucose 67mg/dL. Blood and urine cultures were negative. Anti-dsDNA, C3, and C4 were normal. CT chest showed right lower lobe infiltrates and bronchial debris. She was treated with antibiotics and bronchoscopy with mucus plug removal. Her lethargy and confusion persisted. MRI brain was negative for acute event. Hb fell to 7g/dL; managed conservatively with i.v. iron. CT abdomen showed BAH both measuring 3.5x3.5cm; AM cortisol was 5.5 mcg/dL. Warfarin was reversed with vitamin K; hydrocortisone 50mg q8h was started with improvement in her mental status. ACTH levels were <5pg/ml; ACTH stimulation testing was deferred as steroids were started emergently. Repeat CT showed stable BAH, AM cortisol increased to 19.4mcg/dL, and Hb stable at 8g/dL. She was discharged on hydrocortisone 10mg twice daily. Discussion: Trauma, corticotropin stimulation during stress, anticoagulation therapy, and APS inducing adrenal venous thrombosis have been identified as risk factors that predispose to BAH. There is a lack of consensus regarding normal cortisol levels in critical illness. Fluctuations in serum cortisol levels are frequent and not necessarily indicative of definite injury to the adrenal gland. CT abdomen, the investigation of choice in the acute setting, has a heterogeneous, high density appearance; the presence of an underlying adrenal mass cannot be excluded. BAH appears as diminished attenuation of the adrenal gland with respect to the adjacent tissues, along with thickening of the ipsilateral crura due to retroperitoneal extension of blood (1). MRI has a greater accuracy for identifying BAH in comparison to CT as it can discern adrenal hematoma from adjacent necrotic tissue and determine the acuity of the hematoma. Conclusion: The nonspecific clinical manifestations of BAH are frequently inseparable from those of the concurrent major illness. The diagnosis requires a high index of suspicion, initiation of prompt steroid replacement, and confirmation by CT abdomen. References: (1) Fatima, Z., Tariq, U., Khan, A., et. Al. A Rare Case of Bilateral Adrenal Hemorrhage. Cureus. 2018 Jun; 10(6): e2830. doi: 10.7759/cureus.2830 Oxford University Press 2020-05-08 /pmc/articles/PMC7208497/ http://dx.doi.org/10.1210/jendso/bvaa046.807 Text en © Endocrine Society 2020. http://creativecommons.org/licenses/by-nc-nd/4.0/ This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs licence (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any medium, provided the original work is not altered or transformed in any way, and that the work is properly cited. For commercial re-use, please contact journals.permissions@oup.com
spellingShingle Adrenal
Tavares, Matthew V
Sittol, Rani Delraj
Chang, Sang-Min
Otuonye, Gene
Barnes, Tanganyika
SAT-206 A Sweet and Salty Milieu: The Utility of CT in Bilateral Adrenal Hemorrhage
title SAT-206 A Sweet and Salty Milieu: The Utility of CT in Bilateral Adrenal Hemorrhage
title_full SAT-206 A Sweet and Salty Milieu: The Utility of CT in Bilateral Adrenal Hemorrhage
title_fullStr SAT-206 A Sweet and Salty Milieu: The Utility of CT in Bilateral Adrenal Hemorrhage
title_full_unstemmed SAT-206 A Sweet and Salty Milieu: The Utility of CT in Bilateral Adrenal Hemorrhage
title_short SAT-206 A Sweet and Salty Milieu: The Utility of CT in Bilateral Adrenal Hemorrhage
title_sort sat-206 a sweet and salty milieu: the utility of ct in bilateral adrenal hemorrhage
topic Adrenal
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7208497/
http://dx.doi.org/10.1210/jendso/bvaa046.807
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