Page 23 - Delaware Medical Journal-October
P. 23
CASE REPORT
pheochromocytoma, benign tumor or cysts of the adrenal gland, 4,5 Thrombocytopenia, sepsis, and heparin exposure have also been shown to be independent risk factors for AH.6 The patient in this case had the risk factors of heparin administration and a septic state, but his platelet count was not low and, in fact, was mildly elevated at the time of diagnosis.
The time interval between an episode of high stress or sepsis and development of AH is variable. A multi-center case
control study of bilateral massive adrenal hemorrhage found a latency period of 0 to 151 days between hospital admission and discovery of AH with a median of 11 days. Most of the case reports describing pneumococcal sepsis-associated AH have highlighted that pneumococcal infection can present with a Waterhouse-Friderichsen Syndrome.7–10 In all of these cases the patients died within 24 hours after presentation to a health care where a symptomatic adrenal hemorrhage was diagnosed in the convalescent phase of pneumococcal septic shock.
Pathophysiology
The mechanism whereby severe stress or sepsis precipitates AH is multifactorial. The adrenal glands are thought to be anatomically an abrupt transition into cortical sinusoids and a solitary adrenal vein leading to a vascular dam physiology.3 Additionally, in glands. In the septic state, systemic vasoconstriction as well as
to adrenal necrosis and hemorrhage. In conditions such as pro-thrombotic states, microthrombi and adrenal vein thrombosis may contribute to the pathophysiology.1
Diagnosis
requires a high index of suspicion and use of appropriate imaging. Typical symptoms include abrupt onset moderate to severe upper sternal area. Exam reveals abdominal tenderness, hypoactive bowel sounds, and variable degrees of guarding. Other symptoms include nausea, emesis, altered mental status, and fever. Typical include a modest drop in hemoglobin.4 Severe anemia and hemodynamic instability are possible if the adrenal hemorrhage advances into the retroperitoneum.11 HIT or APS.
FIGURE 1
MRI abdomen with contrast on re-admission day 3. New right adrenal hemorrhage (arrow)
marked by hyponatremia, hyperkalemia, and refractory hypotension.3 Early recognition and treatment of this condition evident after 90 percent or more of adrenal cortical tissue is destroyed.12 occurs in a minority of patients with AH.1,3 In this setting cortisol unless the patient has prior suppression or removal of the contralateral adrenal gland.
on clinical grounds. The physical exam and laboratory results are
such as acute coronary syndrome, pancreatitis, pulmonary embolism,
is necessary to make the diagnosis, and unfortunately, many cases
study in the unstable or symptomatic patient due to its good sensitivity and rapid results.12 When the AH is acute it may be undetected on an 13 Ultrasound has the advantage of being able
to be done at the bedside of critically ill patients, and color doppler
can be used to rule out internal vascularity that occurs with adrenal gland neoplasms or metastasis. However, in some adults it can be size or large patient body habitus. MRI is the most accurate imaging modality to diagnose AH and has the advantage of being able to assess
Del Med J | October 2015 | Vol. 87 | No. 10
311
