Bilateral massive adrenal hemorrhage: early recognition and treatment

To develop a clinical perspective on bilateral massive adrenal hemorrhage and an algorithm for its diagnosis and treatment.

Case reports were identified through a computer search using MEDLIN (1976 to 1987), and from bibliographies in review articles (up to 1978).

Twelve reports published since 1978 were found.

Data from 20 recently reported cases and 5 cases from personal records were compared with data from 142 previously reported, autopsy-proven cases summarized in a 1978 review article.

Thromboembolic disease, coagulopathy, and the postoperative state were the three major risk factors. Except for abdominal pain and remittent fever, clinical features were not helpful in diagnosis. A fall in hemoglobin, and progressive biochemical hypoadrenalism were important clues. Diagnosis was confirmed by computed tomography and an absent cortisol response to intravenous corticotropin. Long-term follow-up showed complete atrophy and functional failure of the adrenal gland.

Death from bilateral massive adrenal hemorrhage can be prevented by pre-emptive steroid therapy in high-risk patients who have certain clinical and laboratory features.