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Adrenal hemorrhage: a 25-year experience at the Mayo Clinic
A Vella1, T B Nippoldt, J C Morris
1Division of Endocrinology, Metabolism, Nutrition and Internal Medicine, Mayo Clinic, Rochester, Minn. 55905, USA. vella.adrian@mayo.edu
Insights
Adrenal hemorrhage (AH) is a varied condition. Early diagnosis with imaging is key, as corticosteroid treatment effectiveness for adrenal hemorrhage varies significantly by underlying cause.
Area of Science:
- Endocrinology
- Internal Medicine
- Pathophysiology
Background:
- Adrenal hemorrhage (AH) is a rare but serious condition.
- Characterizing its clinical course is crucial for improving patient outcomes.
Observation:
- A systematic review analyzed 141 patients with adrenal hemorrhage over 25 years.
- AH presented heterogeneously, associated with postoperative states, antiphospholipid-antibody syndrome, heparin-associated thrombocytopenia, severe stress, and multiorgan failure.
- Standard laboratory tests were not helpful for diagnosis.
Findings:
- Bilateral AH occurred in 78 patients, unilateral in 63.
- Corticosteroid treatment showed limited survival benefit in severe stress or sepsis (9% vs. 6%).
- Outcomes were dramatically different for postoperative AH (100% vs. 17% survival with/without treatment) and antiphospholipid-antibody syndrome (73% vs. 0% survival).
Implications:
- A high index of suspicion and prompt diagnosis via imaging are essential for adrenal hemorrhage.
- Fever and hypotension in specific clinical settings warrant further investigation for AH.
- In severe stress or sepsis, AH may indicate a poor prognosis and preterminal physiologic state.
Objective:
To characterize the clinical course of adrenal hemorrhage (AH) by using a systematic review of the presentation, associated conditions, and outcomes in patients with AH seen at our institution between 1972 and 1997 (a 25-year period).
Patients And Methods:
A computer search of recorded dismissal diagnoses identified 204 patients with a diagnosis of AH, but only 141 fulfilled our study criteria. Their records were analyzed systematically by presentation, bilateral or unilateral hemorrhage, corticosteroid treatment, and survival.
Results:
AH is a heterogeneous entity that occurs in the postoperative period, in the antiphospholipid-antibody syndrome, in heparin-associated thrombocytopenia, or in the setting of severe physical stress and multiorgan failure. Standard laboratory evaluation is not helpful in establishing the diagnosis. Of the 141 cases of AH, 78 were bilateral, and 63 were unilateral. Corticosteroid treatment in situations of severe stress or sepsis had little effect on outcome (9% vs. 6% survival with and without corticosteroid treatment, respectively). This is in sharp contrast to AH occurring postoperatively (100% vs. 17% survival with or without treatment, respectively) or in the antiphospholipid-antibody syndrome (73% vs. 0% survival, respectively).
Conclusions:
A high index of suspicion is required to make a timely diagnosis of AH. Fever and hypotension in the appropriate clinical setting necessitate further investigation. Although the diagnosis of AH is infrequently made while the patient is alive, appropriate imaging techniques are useful for establishing a timely diagnosis. In severe physical stress or sepsis, AH may be a marker of severe, preterminal physiologic stress and poor outcome.