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CASE REPORT
the age of the hematoma: acute (less than seven days), subacute (seven days to seven weeks) or chronic stages (more than seven weeks). MRI with contrast is the also the best modality for assessing for underlying adrenal cysts or neoplasm as a cause of the AH.12
Management
The management of AH depends on several patient factors. Assessment of adrenal function with morning or random cortisol and/ has bilateral adrenal hemorrhage or other risk factors for adrenal empiric therapy with glucocorticoids should be pursued before function, and electrolytes should be drawn to assess for anemia, hyponatremia, hyperkalemia and coagulopathy. If the patient has a known precipitating condition such as trauma, severe stress, surgery, or sepsis an extensive laboratory work-up can be minimized. If pregnancy, pheochromocytoma, or malignancy may be considered.
The question of occult malignancy often occurs when an
underlying benign or malignant tumors. If imaging is not malignancy.14 Surgical consultation is also advised if the AH is large or symptomatic or complicated by retroperitoneal hematoma or abscess formation. The majority of adrenal hematomas pseudocyst.12 If the AH has a known precipitant, as in this case,
it can be treated conservatively with pain control and serial monitoring.15
CONCLUSION
In summary, this patient presented with acute symptomatic AH after
a complete treatment course of pneumococcal pneumonia and septic shock. Unlike many cases reported in the literature, this case was not associated with Waterhouse-Friderichsen syndrome. This case demon- strates several clinical pearls relevant to the diagnosis of AH, including:
1 ThediagnosisofAHrequiresahighindexofsuspicion. Patients can present with vague complaints such as chest and abdominal pain. The laboratory work-up is typically unrevealing.
2
3 imaging may be required.
4 AHshouldbeconsideredinthedifferentialofabdominalpain in those in the critical care setting, especially if they are septic, thrombocytopenic, or receiving heparin.
5 AHcanoccurinthedaystoweeksafteraperiodofacute stress in the convalescent period.
CONTRIBUTING AUTHORS
■ JEFF WHARTON, MD is a senior Internal Medicine Resident at Christiana Care Health System in Newark, Del. After he completes his residency, he will pursue a career in primary care with Kaiser Permanente in Gaithersburg, Md.
■ DAVID COHEN, MD is an Infectious Disease Specialist at Christiana Care Health System in Newark, Del. where is serves as Section Chief of Infectious Disease and is a member of the Executive Committee.
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