MON-497 - Changing the Tempo: A Rare Case of Atraumatic Hyperacute Bilateral Adrenal Hemorrhage with Complete Glandular Involvement Ensuing Normal Imaging

Bilateral adrenal hemorrhage (BAH) is a rare, life-threatening condition associated with sepsis, anticoagulation, antiphospholipid syndrome (APS), trauma and malignancy. It can precipitate acute primary adrenal insufficiency (AI), which is fatal if unrecognized. Clinical presentation is often nonspecific and diagnosis relies on imaging. Although BAH is recognized in critical illness, the tempo of its development remains poorly characterized.

A 51-year-old female with hypertension, substance use disorders (methamphetamine, fentanyl), metastatic melanoma (status post resection) presented with weight loss, nausea, vomiting, and diarrhea for several days. She was admitted with septic shock of presumed genitourinary origin and treated with antibiotics. CT abdomen with contrast on hospital day (HD) 1 demonstrated normal adrenal glands. She received enoxaparin for DVT prophylaxis and was discharged.

She re-presented on HD9 with recurrent abdominal pain, diarrhea and ongoing weight loss. Repeat CT abdomen revealed new-onset bilateral adrenal hematomas measuring 4.5cm (right) and 2.3cm (left), representing complete interval transformation from normal glands to substantial bilateral hemorrhage within 8 days, without interval trauma. APS evaluation, including lupus anticoagulant, beta-2 glycoprotein, and cardiolipin antibodies were negative.

Laboratory studies on HD10 showed AM cortisol 14.5 mcg/dL [4.8–19.5], ACTH 43 pg/mL [6–50], aldosterone < 1 ng/dL [≤28], DHEA-S 21 mcg/dL [16–295], and plasma renin activity 2.62 ng/mL/hr [0.25–5.82], all within reference ranges.

Her course was complicated by colon perforation requiring surgery on HD14, during which therapeutic heparin anticoagulation was initiated. She received blood transfusion during hospitalization. Repeat CT on HD18 showed stable hematomas (4.5cm right, 2.5cm left). On HD19, AM cortisol acutely declined to 2.3mcg/dL [4.8-19.5] by HD21. Gastrointestinal biopsies showed no evidence of melanoma, reducing concern for metastatic adrenal involvement. Multidisciplinary review favored stress-induced bilateral adrenal hemorrhage.

This case demonstrates hyperacute BAH with complete radiographic evolution from normal adrenal glands to bilateral hematomas within 8 days in the setting of sepsis and anticoagulation. This rapid progression underscores that BAH may develop over days and may be absent on initial imaging. Serial clinical, biochemical, and imaging reassessment is critical, as adrenal insufficiency may emerge later. Early recognition and prompt glucocorticoid therapy are essential to prevent adrenal crisis. Follow-up imaging at 2-3 months is recommended to confirm resolution and exclude underlying pathology.

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