A Rare and Unusual Case of Hypernatremic Dehydration in a Newborn Presenting With Adrenal Haemorrhage and Leading to Acute Kidney Injury.

Adrenal haemorrhage, although a rare entity in the neonatal period, is a known complication of birth asphyxia. Adrenal haemorrhage progresses differently depending on the type and extent of the glands involved. Adrenal haemorrhage can cause persistent jaundice, fever, dehydration, scrotal swelling, abdominal wall discolouration, septicemia, and a shock-like state. Here, we report the case of a four-day-old male infant who presented with jaundice, poor feeding, and hypernatremic dehydration. The patient developed acute kidney injury and, eventually, renal failure due to adrenal haemorrhage. He had an abdominal lump with deranged renal parameters along with hyperbilirubinemia. Abdominal ultrasonography and contrast computed tomography scan showed left suprarenal enlargement with evidence of adrenal haemorrhage. The patient was managed well with ventilatory support and peritoneal dialysis and discharged successfully. A subsequent follow-up showed complete resolution of the adrenal haemorrhage. Single ultrasonography is a good modality for diagnosis but not sufficient, so serial ultrasonography at subsequent follow-up is a must.

Dabigatran Etexilate Related Unilateral Adrenal Hemorrhage.

A 63-year-old male presented to our clinic with computed tomography data of a large tumor of the left adrenal gland. The formation is highly suspicious for malignancy with central necrosis and hemorrhage, and a total size of 197/183/201 mm. Due to elevated D-dimer values of 7.17 mg/l (reference range <0.5 mg/l), treatment with dabigatran etexilate 2x150 mg was prescribed following a cardiology consult. On the third day of therapy, the patient noticed a large swelling in the left abdominal flank, which caused discomfort. No additional symptoms were reported. No previous abdominal surgical interventions or trauma were reported. Following a thorough physical examination, the patient was referred for a computer tomography that reported a diagnosis of a tumor of the left adrenal gland. Due to the size of the neoplasm, the suspicion of malignancy, compression of adjacent structures, and significant anemia with an Hb of 112 g/L, operative treatment was chosen as the best treatment modality. The mass was reported as a large organizing adrenal hematoma with no suspicion of malignancy on histology. Following a review of available literature, no other cases of unilateral adrenal hematoma with a size of 201x197 mm, following oral anticoagulant therapy with dabigatran etexilate, without any prior surgery or trauma have been reported. Most clinical cases report bilateral adrenal hemorrhage during the postoperative period, following prophylaxis with heparin and the development of heparin-induced thrombocytopenia. The patient underwent operative treatment, after which the patient recovered normally and was discharged from the clinic without complications.

Unilateral Traumatic Adrenal Hemorrhage with Shock.

Trauma to the adrenal glands is very rare. The variation in clinical manifestations is marked and markers for its diagnosis being limited, makes it tough to be diagnosed. Computed tomography remains the gold standard for detecting this injury. Prompt recognition and the potential for mortality with adrenal insufficiency can provide the best guidance for the treatment and care of the severely injured. We present a case of a 33-year-old trauma patient who was not responding to the management of his shock. He was finally found to have a right adrenal haemorrhage leading to adrenal crisis. The patient was resuscitated in the Emergency Department but succumbed 10 days post admission.

Acute adrenal insufficiency secondary to bilateral adrenal haemorrhage.

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Rapid identification of bilateral adrenal and pituitary haemorrhages induced by Russell's viper envenomation results in positive patient outcome.

The clinical management of snakebite envenomation (SBE) is challenging in many tropical and subtropical regions of developing countries due to the complex clinical manifestations and inadequate medical infrastructure. Some venomous snakes, such as the Indian Russell's viper (Daboia russelii) cause a wide range of rare complications in addition to their classical envenomation effects. In general, these uncommon complications are often misdiagnosed or not treated promptly due to a lack of awareness about these conditions. Thus, it is critical to report such complications to draw the attention of the healthcare and research communities to improve the clinical management and scientific research of SBE, respectively. Here, we report bilateral adrenal and pituitary haemorrhages in an SBE patient following a bite by Russell's viper in India. The initial symptoms included gum bleeding, swelling, axillary lymphadenopathy and clotting abnormalities. Despite the administration of antivenom, the patient presented palpitation, nausea, and abdominal pain, which were not recovered by combinational therapy with epinephrine and dexamethasone. Further infusion of antivenom did not address these issues and the patient displayed persistent hypotension, hypoglycaemia and hyperkalaemia suggesting an adrenal crisis. Inadequate secretion of corticosteroids was confirmed by laboratory tests, and imaging investigations revealed haemorrhages in both the adrenal and pituitary glands. The patient made a full recovery after treatment with hydrocortisone and thyroxine. This report adds to the growing evidence of rare complications induced by Russell's viper envenomations and it provides relevant guidance to diagnose and treat such complications in SBE victims.

Bilateral Adrenal Hemorrhage Following Femoral Hip Hemiarthroplasty: A Case Report.

Bilateral adrenal hemorrhage (BAH) is a rare and potentially fatal complication following total hip arthroplasty and low-molecule heparin use for DVT-prophylaxis. We present a case of a 64-year-old woman who sustained a femoral neck fracture, which was addressed with hip hemiarthroplasty. Twelve days postoperatively DVT was diagnosed and therapeutic doses of low-molecule-heparin were administered. The next day, CTPA was done searching for pulmonary embolism but BAH was shown and a short synacthen test confirmed the diagnosis of adrenal insufficiency. A therapeutic protocol with hydrocortisone was followed.

Idiopathic Bilateral Adrenal Haemorrhage in an Otherwise Healthy Patient.

This is the case of a lady with a bilateral adrenal haemorrhage with no known cause. She presented with abdominal pain that progressed to back pain with rising serum lactate. The initial and repeat computerized tomography (CT) scans were unremarkable apart from small bilateral renal stones. She was ultimately treated conservatively in the hospital and discharged. On a follow-up appointment and CT scan, it was discovered that she had small bilateral adrenal haemorrhages. She was followed in the clinic until symptomatic resolution which did eventuate, and she was subsequently discharged. The case highlights that with no antecedent factors or past medical history combined with no hemodynamic instability, bilateral adrenal haemorrhages would be a diagnosis to reach but should remain in the differential.

A Rare Case of an Isolated Left Adrenal Haematoma in Blunt Force Trauma.

Isolated left adrenal gland injuries following blunt abdominal trauma are extremely rare, accounting for only 1.5-4% of all adrenal trauma cases. Most traumatic injuries are right-sided and associated with other concurrent organ injuries. While acute, unilateral adrenal injuries can be asymptomatic, it is important to recognise the potentially life-threatening complications from haemorrhage and/or adrenal insufficiency. Due to its rarity, there are currently no established guidelines for management, monitoring, or follow-up of adrenal gland trauma. We present a case report of a rare, isolated, post-traumatic left adrenal gland haemorrhage. A 39-year-old man presented with mild abdominal pain following a mountain bike accident. Initial assessment revealed tenderness in the left upper quadrant with normal vital signs and biochemistry, but computer tomography (CT) imaging demonstrated an enlarged left adrenal gland with regional fat stranding and free fluid consistent with an acute adrenal haematoma. He was admitted to the ward for observation and discharged on day three of admission. At a six-week follow-up, he reported a complete resolution in symptoms. Follow-up CT of the adrenals at five months post-injury demonstrated complete resolution of the isolated adrenal haematoma. Post-traumatic isolated left adrenal gland injuries are rare in the reported literature, and this case highlights the lack of current guidelines for management and monitoring in cases of isolated adrenal haemorrhage. The current consensus appears to be appropriate with conservative management and follow-up with serial abdominal CT until the resolution of haemorrhage and/or symptoms.

Unilateral Adrenal Hemorrhage: A Rare Complication of Anticoagulant Use.

Unilateral adrenal hemorrhage is a rare but deadly complication that can occur secondary to causes such as trauma and metastasis. A 55-year-old male with a history of metastatic lung adenocarcinoma and deep vein thrombosis managed with rivaroxaban presented with acute right abdominal and flank pain. A CT angiogram of the abdomen showed a retroperitoneal hematoma around the right adrenal gland, consistent with a unilateral adrenal hemorrhage. An MRI showed no signs of adrenal metastasis and the patient had no history of trauma. The volume of the hematoma did not change in size and the patient was hemodynamically stable, which only prompted supportive management. Anticoagulant use is a known risk factor for bilateral adrenal hemorrhage. However, this case demonstrates that unilateral adrenal hemorrhage can also be a complication, one that usually appears subclinically. It can present non-specifically but may progress to a more fatal bilateral hemorrhage. Hence, it demands a high index of suspicion for patients on systemic anticoagulation.

A Case of Bilateral Adrenal Hemorrhage: The Exceptional Cause of Adrenal Insufficiency.

Bilateral adrenal hemorrhage is an extremely uncommon and life-threatening condition. It is caused by multiple etiologies, including antiphospholipid syndrome, disseminated histoplasmosis, trauma, severe stress, and granulomatous disease. The authors present a unique case of a 64-year-old alcoholic male, who was admitted after fall and right hip fracture. On day seven of admission, the patient started to develop hypotension, leukocytosis, and tachycardia. CT abdomen was done, which ruled out infectious causes, however, it showed bilateral adrenal hemorrhages. Patient adrenocorticotrophic hormone (ACTH) stimulation test was positive for adrenal insufficiency and was started on hydrocortisone replacement. Our case highlights the fact that adrenal insufficiency after bilateral adrenal hemorrhage can be slow and can manifest as late as seven days and prompt therapy with steroids is warranted to avoid life-threatening adrenal insufficiency.

Lupus anticoagulant hypoprothrombinemia syndrome associated with bilateral adrenal haemorrhage in a child: early diagnosis and intervention.

BACKGROUND: Lupus anticoagulant-hypoprothrombinemia syndrome (LAHPS) is characterized by bleeding and thrombosis in patients with autoimmune diseases or infections. Paediatric LAHPS exhibits various degrees of bleeding, ranging from mild to severe; however, adrenal haemorrhage due to LAHPS and its long-term clinical course have not been sufficiently described. CASE PRESENTATION: A 9-year-old boy presented with prolonged abdominal pain and abnormal coagulation screening tests. The laboratory tests showed prolonged activated partial thromboplastin time and subsequently revealed the presence of lupus anticoagulant, anti-nuclear antibodies, and hypoprothrombinemia, leading to diagnosis of LAHPS. An enhanced computed tomogram demonstrated nodular lesions in the adrenal glands bilaterally, suggestive of adrenal haemorrhage. Laboratory and clinical manifestations exhibited life-threatening adrenal insufficiency that required hydrocortisone administration. The patient developed systemic lupus erythematosus, diagnosed 12 months later. CONCLUSIONS: This patient with LAHPS developed rare adrenal failure due to adrenal haemorrhage, a life-threatening event that should be recognized and treated early. In our case, renal dysfunction was also observed when systemic lupus erythematosus was diagnosed 1 year after LAHPS. Our case emphasizes that early recognition of adrenal failure and careful long-term observation is required in patients with autoantibodies.

Bilateral Neonatal Adrenal Hemorrhage Associated With Severe Maternal COVID-19 Infection.

Adrenal hemorrhage is the most common cause of adrenal mass in newborns. We present a case of a full-term male, born by cesarean section due to acute fetal distress from a mother with severe coronavirus disease 2019 (COVID-19) infection. He was diagnosed with hypoxic-ischemic encephalopathy, multifactorial shock, and early neonatal sepsis. On the seventh day of hospitalization, hemoglobin dropped and thus blood transfusion was required, and abdominal ultrasound showed bilateral adrenal hemorrhage. He developed relative adrenal insufficiency without either hemodynamic instability or electrolyte imbalances. The use of parenteral corticosteroids was not required. Follow-up ultrasonography and adrenal axis laboratory examination revealed complete resolution of adrenal hemorrhage. Neonatal adrenal hemorrhage has a wide variety of clinical manifestations. Ultrasound is preferred for both initial screening and follow-up evaluation. Adrenal insufficiency occurs rarely in neonatal adrenal hemorrhage. Treatment is usually conservative. We emphasize the importance of a timely diagnosis and clinical follow-up of adrenal hemorrhage in neonates with fetal distress born from mothers with severe COVID-19.

A Rare Case of Waterhouse-Friderichsen Syndrome Without Purpura Secondary to Haemophilus Influenzae.

The Waterhouse-Friderichsen syndrome is an entity consisting of shock, petechial rash and haemorrhages in both adrenal glands leading to adrenal failure. This syndrome is usually secondary to meningococcal septicaemia, but there are many documented cases caused by other bacteria. Purpura is an essential part of the syndrome, but it is not always there. In the current study, a case of Waterhouse-Friderichsen syndrome without purpura in an elderly patient with Haemophilus influenzae bacteraemia has been described. This patient was being managed for sepsis due to pneumonia and an incidental finding of bilateral adrenal haemorrhage was made on a CT of the thorax which was meant to evaluate empyema. This case shows the need to suspect bilateral adrenal haemorrhage in every patient with septic shock.

Haemorrhage in pre-existing adrenal masses. A case series.

INTRODUCTION: Adrenal haemorrhage in the context of a pre-existing adrenal mass is a rare, underestimated and potentially fatal surgical emergency. It is a rare cause of acute abdominal pain. PRESENTATION OF CASES: Data from 13 patients with adrenal haemorrhage in a pre-existing adrenal mass were prospectively collected during a 9 year period from a single institution. All patients underwent CT imaging which formed the basis of diagnosis and a complete endocrinological evaluation. Seven out of 13 patients underwent an elective surgical procedure and 2 patients underwent emergency laparotomy. Five out of 13 patients were diagnosed with metastatic disease. One patient was diagnosed with pheochromocytoma. DISCUSSION: The likelihood of an undiagnosed pheochromocytoma renders emergency surgery extremely precarious. Complete patient evaluation includes testing for hormonally active adrenal tumors and malignancy. Emergency surgery is reserved for cases where conservative management fails. CONCLUSION: Haemorrhage of an adrenal mass constitutes a diagnostic and therapeutic challenge. Most patients respond well to initial resuscitation efforts. When feasible, patients should undergo a complete hormonal and oncologic evaluation before surgical intervention is considered.

Bilateral adrenal haemorrhage after a high energetic trauma: a case report and review of current literature.

Most adrenal injuries are asymptomatic. In traumatic events, adrenal haemorrhage is very likely to be accompanied by injuries to other organs. Isolated adrenal injury after trauma is very rare and mostly unilateral. We report a case of a 44-year-old male who suffered a major traffic accident with multiple trauma, including a bilateral adrenal haemorrhage. This caused a primary adrenal insufficiency, as proven with a cortisol stimulation test with synthetic corticotrophin. Bilateral adrenal haemorrhage is a very rare but potentially fatal disorder and should not be missed. This case illustrates that early diagnosis and prompt treatment with hydrocortisone may contribute to a beneficial outcome.

Acute non-traumatic adrenal haemorrhage-management, pathology and clinical outcomes.

BACKGROUND: Acute adrenal haemorrhage is a rare medical emergency. The aim of the series was to study the clinical presentation and management of patients presenting with acute non-traumatic adrenal haemorrhage. METHODS: The records of patients presenting with an acute abdomen secondary to adrenal haemorrhage and treated in a tertiary endocrine surgical unit over a period of 6 years were reviewed. RESULTS: Of the 11 included patients, there were 4 males and 7 females; the median [range] age at presentation was 58 [27-89] years. All were initially managed conservatively for bleeding, except one who underwent angioembolisation to ensure hemodynamic stability. Two patients underwent percutaneous drainage of persistent collection and suspected sepsis. Biochemical workup showed hyper function with metanephrine excess in 1 patient. Adrenalectomy was performed in 5 patients after a median [range] of 10 [7-11] weeks. Histology showed benign pathology in 2 patients, malignant in 2 patients and necrotic tumour in 1 patient. Two patients died of disseminated metastatic disease at 5 and 2 months after presentation with bleeding. Conservative management in the other 3 patients was successful at a median follow up of 26 [6-66] months. CONCLUSIONS: Acute adrenal haemorrhage is usually associated with an underlying pathology; which may be benign or malignant; functional or non-functional. Initial conservative management is preferred as it allows determination of functional status and elective surgery, if necessary.

Acute adrenal insufficiency due to adrenal hemorrhage complicating colorectal surgery: Report of two cases and correlation with the antiphospholipid antibody syndrome.

INTRODUCTION: Spontaneous bilateral adrenal hemorrhage or hemorrhagic necrosis due to adrenal vein thrombosis is an uncommon condition that may lead to acute adrenal insufficiency and death. The objective of this report is to enhance recognition of this potentially fatal disorder in surgical patients. PRESENTATION OF CASES: We present two cases of acute adrenal insufficiency due to bilateral adrenal hemorrhage associated with primary antiphospholipid antibody syndrome (APS). Both cases occurred in the early postoperative period after major colorectal surgery. Major vein thrombosis, abdominal pain, anorexia, asthenia, lethargy and an unexplained drop in patient's hemoglobin without evidence of sepsis were the principal symptoms and signs that, with a high index of suspicion, led to the correct diagnosis. DISCUSSION: Antiphospholipid syndrome is an acquired thrombophilia caused by circulating antibodies against a heterologous group of phospholipids. Recent literature has identified a causative relation between APS and primary adrenal insufficiency (AI), identifying it as its most common endocrine manifestation. Surgeries along with inflammation or hormones have been identified as precipitating factors. Spontaneous haemorrhagic infarction of the adrenal glands has been observed in patients with APS in the postoperative period during anticoagulant treatment. Signs and symptoms are non-specific and are easily confused with those of the underlying condition. CONCLUSIONS: Early recognition and prompt treatment of adrenal insufficiency due to APS in surgical patient is of vital importance. Patients correctly diagnosed and treated that survive the critical phase have a better prognosis regarding restoration of adrenal function.

An unusual presentation of a birth trauma in a newborn: A case report.

A term, male infant weighing 4.725 kg, was born vaginally to a grand multipara, diabetic mother. The birth was difficult and needed assistance with ventose. At 48 hours of birth, the infant noted to be febrile (temperature of 38.5C) with dry skin. Shortly after that, he developed vomiting, loose motions, irritability, and seizure. Examination revealed a macrosomic, normotensive infant, with slightly prolonged capillary refill time (3 sec), clear lung fields, normal heart sounds, bilaterally palpable renal masses which was ovoid, smooth, and 10 × 5 cm in size. Other systems were normal including normal male genitalia. Investigations were normal, apart from hypoglycaemia (random blood sugar of 48 mg/dl), hyponatraemia (Na = 129 mmol/l), and hyperkalaemia (K = 6.7 mmol/l). A salt loosing congenital adrenal hyperplasia was suspected and the abdominal ultrasound (U/S) scanning showed isolated bilateral adrenal haemorrhage. The infant started on hydrocortisone and fludrocortisone. In conclusion, we here report an isolated adrenal haemorrhage that caused adrenal insufficiency in an infant of diabetic mother.

Large bilateral adrenal haemorrhages in a newborn with unrepaired cyanotic CHD.

Management of newborns with cyanotic CHD and bilateral adrenal haemorrhages has not previously been described in the literature. These abnormalities present unique challenges due to the potential for haemodynamic instability, need for open heart surgery and associated systemic anticoagulation in the newborn period, and the risk of catastrophic bleeding.