Idiopathic Unilateral Adrenal Hemorrhage

Presentation Number: SAT-0770
Date of Presentation: June 21st, 2014

Maria Patricia Gamboa Puno*, Elizabeth P Pacheco, Adriano Dela Paz, Stephanie Mae O. Ang, Gregorio B. Cortez III and Elizabeth Ann S. Alcazaren
The Medical City, Pasig City, Philippines

Abstract

Hemorrhage to the adrenal glands is a rare finding occurring more frequently in children than in adults.  It is classically associated with meningococcal septicemia (Waterhouse–Friderichsen syndrome).  In adults, it is mainly caused by trauma, surgical stress,  anticoagulation therapy, or a tumor; however, spontaneous or idiopathic adrenal hemorrhage is extremely rare.  

We report a case of a 72 year old male, hypertensive, diabetic, presenting with an a palpable soft, non-tender right lumbar mass. He had no history of trauma nor intake of anti-coagulants and was otherwise well with good functional capacity. A CT scan was done and revealed a large heterogeneous mass lesion with a central hypodense component (likely necrosis) centered in the right retroperitoneal region, with non-contrast Hounsfield units ranging from 15-40 HU. It measured 14.2 x 12.5 x 14.7 cm, with neovascularities and small calcific components.  A possible adrenal neoplasm was considered. A hormonal work-up was subsequently done revealing a non-functioning adrenal mass.  The results:  Plasma Aldosterone-RIA 23.77 ng/dl (NV: 3.0-35.5 ng/dl), Plasma Renin Activity 5.65 ng/ml/hr (0.5-1.9 ng/ml/hr supine; 1.9-6.0 ng/ml/hr upright), ARR:  4.207, Serum Cortisol (8am): 15.7 ug/dl (nv 4.2 – 38.4), 24h urine metanephrine: 1.21 mg/24hr (nv up to 1 mg metanephrine/24 hr ); DHEA-S: 69.5 ug/dl (nv 33.6-249); Progesterone: 0.26 ng/ml (nv 0.2-1.31); Testosterone: 3.31 ng/ml (nv 1.95 – 11.38); Estradiol: 29 pg/ml (nv 20-77).  A biopsy of the adrenal mass was then done however results were inconclusive.  Exploratory laparotomy and resection of the retroperitoneal mass was done with a histopathologic finding of a diffuse adrenal hemorrhage on the right. 

Adrenal hemorrhage is an uncommon condition and is difficult to diagnose because of its nonspecific presentation that the diagnosis is often made at autopsy. The value of imaging modalities with the use of CT scan or MRI allows one to determine certain characteristics of an adrenal mass that can point to a benign or malignant tumor. The size and characteristics of the adrenal mass of this patient on CT scan indicated a possibility of malignancy.  Further hormonal work-up was warranted and only on post surgical histopathology was the diagnosis of adrenal hemorrhage made.  This patient, with no known predisposing factors for bleeding, with no history of intake of anti-coagulant nor history of trauma suffered from an idiopathic adrenal hemorrhage without any hormonal disturbances.

 

Nothing to Disclose: MPGP, EPP, AD, SMOA, GBC III, EASA