SAT-476 A Case of Spontaneous Unilateral Adrenal Hemorrhage in the Setting of Cushing’s Syndrome

Abstract Disclosure: M. Ahmed: None. A. Patel: None. S. Simon: None. Introduction: Adrenal hemorrhage in the context of Cushing’s syndrome is a rare but significant complication. There are many causes that can lead to adrenal hemorrhage, including adrenal tumors, coagulopathies, or infectious disease. Therefore, it is often difficult to determine the etiology. This report explores the case of a patient with cushingoid features presenting with spontaneous left adrenal hemorrhage. Case Presentation: A 47-year-old man with a history of hypertension and clinical features of Cushing’s syndrome, including abdominal striae, dorsal fat pad and 80-lb weight gain, presented with left upper quadrant and left flank pain. CT findings were consistent with active hemorrhage in the left upper quadrant, suspicious for an adrenal mass or nodule in origin. The patient underwent left superior adrenal artery embolization. Repeat CT Abdomen/Pelvis three days after embolization showed a stable left adrenal hematoma. Endocrinology and Infectious Disease were consulted to evaluate the etiology of the adrenal hemorrhage. Infectious work up which included HIV, hepatitis, fungal antibodies, Tb, CMV, Typhus, were all negative. Notable labs included an elevated 24-hour urine cortisol, normal salivary cortisol level, elevated cortisol level after a high dose dexamethasone suppression test, decreased ACTH levels, normal serum metanephrines and elevated serum normetanephrines. These findings indicated an adrenal source of excessive cortisol production. Given the acute presentation, lab and imaging findings, the differential diagnosis included adrenal adenoma, pheochromocytoma, or adrenocortical carcinoma. The patient was scheduled for outpatient monitoring and treatment, including repeat CT imaging and consultation to discuss left adrenalectomy. Discussion: Adrenal hemorrhage is rare and can result from a variety of causes. Literature review shows abdominal trauma, infections, surgery, angiography, adrenal venous thrombosis, adrenal tumors, coagulopathy, antiphospholipid syndrome, pheochromocytoma, and ACTH administration as some of the possible etiologies. This report explores the pathophysiology of adrenal artery rupture in the setting of Cushing’s syndrome. Various mechanisms, including vascular fragility, hypertension, increased intra-adrenal pressures from adenomas, arteriosclerotic changes and potential thrombosis, can contribute to the increased risk of hemorrhage. In summary, this case highlights the importance of considering the risk of adrenal hemorrhage in patients with adrenal masses and/or hypercortisolism. Detailed hormonal and imaging evaluations are crucial for accurate diagnosis and management. Presentation: Saturday, July 12, 2025