SAT-417 Crashing into Adrenal Insufficiency: A Case of Adrenal Hemorrhage

Abstract Disclosure: F. Noor: None. S. Siddalingaiah: None. S.R. MacLeod: None. Bleeding within the capsule of the adrenal gland is rare and most typically related to surgical trauma, sepsis, coagulopathy, underlying adrenal tumor, or as a postoperative complication. The incidence ranges from 0.8 to 2% with trauma, usually occurring within the first three weeks of illness or post-operative period (Zhu, 2011). Bilateral adrenal hemorrhage accounts for ∼10% of adrenal hemorrhages (Aloini, 2023). Primary adrenal insufficiency may develop in three-fourths of patients with bilateral adrenal hemorrhage (Dogra, 2023). Here, we present a case of adrenal hemorrhage leading to adrenal insufficiency.A 61-year-old male presented after a motor vehicle accident. He was hemodynamically unstable with tachycardia and hypotension. Work up showed anemia and bilateral lower extremity and the left upper extremity fracture. Massive transfusion protocol was initiated, and the patient underwent open reduction and internal fixation and a right hip total arthroplasty. One week later, the patient was improving and planned for discharge to a skilled nursing facility. However, he developed acute severe abdominal pain associated with nausea, vomiting, dizziness, fatigue and a macular, pruritic rash located on his back. He was febrile to 100.6°F and tachycardic with a heart rate of 107. Labs demonstrated leukocytosis. CT abdomen and pelvis with IV contrast revealed acute right adrenal hematoma; periadrenal edema and slight interval thickening of the left adrenal gland, concerning for left adrenal hemorrhage. Initially this was treated as sepsis with antibiotics, but infectious work-up was unrevealing. The patient then became hypotensive with hyponatremia and hyperkalemia. Random cortisol level was 7.5 ug/dL and cortisol stimulation test results were consistent with adrenal insufficiency. The patient was started on stress dose steroids and had significant clinical improvement. The hydrocortisone dose was reduced to physiological dose and fludrocortisone was started.The most likely etiology of this patient’s adrenal hematoma was trauma. There is high prevalence of adrenal insufficiency in bilateral adrenal hemorrhage. This may present as acute adrenal crisis, shock, and even death. Early recognition with imaging studies is thus an important prognostic factor, as is early initiation of treatment. While recovery of adrenal function is rare, it is important to follow-up outpatient to assess for the possibility. Repeat imaging may also be necessary to exclude an underlying adrenal tumor. On repeat imaging, adrenal hematoma may decrease in size and attenuation over time (Elhassan, 2023).In conclusion, bilateral adrenal hemorrhage is a rare cause of adrenal insufficiency. This case demonstrates the importance of having a high index of suspicion for diagnosis, given that the clinical manifestations can be nonspecific and may be hard to differentiate from concurrent major illness. Presentation: Saturday, July 12, 2025