Bilateral adrenal haemorrhage (BAH) is a rare and underrecognised clinical entity which may lead to adrenal insufficiency, and delayed diagnosis can be life-threatening. The pathogenesis of BAH is poorly understood but may be related to the unique vascular anatomy of the adrenal glands and their response to physiological stress. Previous case reports suggest that BAH is usually associated with systemic conditions, such as surgery, sepsis, or coagulopathies.
A 67-year-old lady was referred to the Emergency Department with 4 weeks of lower back pain which had recently intensified. She had associated nausea and lower abdominal pain radiating to her left flank. She was a lifelong non-smoker and had no regular medications. She was haemodynamically stable and had left-sided renal angle tenderness on examination. Contrast-enhanced abdominal imaging and subsequent dedicated adrenal imaging revealed bilateral adrenal haemorrhages measuring 53x43x46mm (left) and 43x14mm (right), alongside an 18x15mm subcutaneous soft tissue lesion in the right anterior chest, raising concerns of potential malignancy. She had a morning cortisol of 244 nmol/L (sampling at 06:55AM), no electrolyte derangement (Na 138mmol/L, K 3.8mmol/L), and a negative coagulopathy screen. Glucocorticoid therapy was initiated for presumed adrenal insufficiency.
Subsequent imaging revealed an additional right lung nodule measuring 57x28x51mm and a 15mm hypodensity in the left thyroid lobe. Whole body FDG-PET/CT confirmed disseminated malignancy which also involved both adrenal glands. Core biopsies of her subcutaneous soft tissue nodule and right lung nodule, and fine needle aspirate of her left thyroid nodule revealed large cell carcinoma. The site of origin could not be determined through immunohistochemical analysis.
This case describes BAH as the initial manifestation of metastatic large cell carcinoma, likely originating from the lung. Adrenal neoplasms are an uncommon cause of BAH, with most cases being attributed to underlying adrenal metastases and rarely to primary adrenal neoplasms such as pheochromocytoma.