Concurrent bilateral adrenal haemorrhage and pulmonary emboli following emergency total hip replacement

Bilateral adrenal haemorrhage (BAH) is a rare but potentially fatal condition. Its non-specific presentation makes diagnosis difficult, delaying treatment. Pulmonary embolism is commonly seen postoperatively, however, its standard treatment conflicts with active haemorrhage. We present the case of a woman in her 70s who underwent a hip replacement for a neck of femur fracture. Postoperatively, she developed epigastric pain, vomiting, fever and lethargy. Intravenous antibiotics were started to minimal avail. A CT scan found bilateral pulmonary emboli and appearances consistent with BAH. Intravenous hydrocortisone was started resulting in a drastic improvement in her condition. Plain adrenal CT confirmed BAH, and the decision was made to insert an inferior vena cava filter instead of anticoagulation. This case demonstrates the difficulties in making a diagnosis of BAH. The condition should be suspected in patients with unexplained systemic decline. It also highlights the clinical dilemma of managing conflicting morbidities.