Causes of Adrenal Hemorrhage
Adrenal hemorrhage is primarily caused by anticoagulant therapy, infections (especially sepsis), trauma, coagulopathy, antiphospholipid syndrome, and underlying adrenal tumors. Understanding these causes is crucial for early recognition and management of this potentially life-threatening condition.
Major Causes of Adrenal Hemorrhage
1. Coagulation Disorders and Anticoagulant Therapy
- Anticoagulant medications: Both traditional anticoagulants and direct oral anticoagulants (DOACs) can cause adrenal hemorrhage 1, 2, 3
- Anticoagulant-related hemorrhage can occur even when anticoagulation parameters are within therapeutic ranges 2
- Prophylactic subcutaneous heparin has been documented to cause bilateral adrenal hemorrhage 4
- Disseminated intravascular coagulation (DIC) 5
- Antiphospholipid syndrome 5
2. Infections
- Bacterial infections: Mycobacteria (tuberculosis), meningococcus, Haemophilus influenzae 5
- Fungal infections: Pneumocystis carinii 5
- Viral infections: HIV, herpes simplex, cytomegalovirus 5
- COVID-19: Recently recognized as a potential cause 6
3. Trauma and Surgery
- Abdominal trauma 6
- Surgical procedures: Tumor surgery, Cushing's syndrome surgery, radical nephrectomy 5
- Post-surgical complications: Particularly following orthopedic procedures with prophylactic anticoagulation 4
4. Underlying Adrenal Pathology
5. Other Causes
- Vaccine-induced immune thrombocytopenia and thrombosis 6
- Severe physiological stress 2
- Hypotension episodes (can both precede and result from adrenal hemorrhage) 2
Clinical Presentation and Risk Factors
High-Risk Clinical Scenarios
- Unexplained abdominal or flank pain with hemodynamic instability 6
- Hypotensive episodes in patients on anticoagulation therapy 2
- Deteriorating condition in critically ill patients, especially with sepsis 4
- Sudden onset of symptoms resembling adrenal insufficiency (nausea, vomiting, confusion, hypotension) 1
Warning Signs of Adrenal Hemorrhage
- Abdominal or flank pain
- Unexplained fever
- Hypotension refractory to fluid resuscitation
- Electrolyte abnormalities (hyponatremia, hyperkalemia)
- Unexplained drop in hemoglobin 4
Special Considerations
Bilateral vs. Unilateral Hemorrhage
- Bilateral adrenal hemorrhage can lead to acute adrenal insufficiency and potentially fatal adrenal crisis 6
- Unilateral hemorrhage may be asymptomatic or present with localized pain
Diagnostic Challenges
- Often diagnosed incidentally on imaging rather than through clinical suspicion 6
- Can be misdiagnosed as sepsis due to overlapping symptoms like fever and hypotension 4
- May present with symptoms mimicking autoimmune Addison's disease 1
Clinical Implications
Adrenal hemorrhage requires prompt recognition and treatment, especially when bilateral, as it can lead to adrenal insufficiency. Physicians should maintain a high index of suspicion in patients with risk factors, particularly those on anticoagulation therapy, with sepsis, or following trauma or surgery.
For patients with confirmed adrenal insufficiency due to hemorrhage, immediate administration of hydrocortisone (100mg IV bolus followed by continuous infusion of 200mg/24h) is recommended to prevent adrenal crisis 5.
Understanding these causes allows for earlier diagnosis and intervention, potentially preventing the life-threatening consequences of adrenal hemorrhage.