Signs and Symptoms of Adrenal Infarction
Adrenal infarction presents with nonspecific clinical features including abdominal pain, hypotension, and signs of adrenal insufficiency, requiring a high index of suspicion in patients with predisposing conditions such as antiphospholipid syndrome, coagulopathy, or COVID-19 infection. 1
Clinical Presentation
Cardinal Signs and Symptoms
- Unexplained abdominal pain with hemodynamic instability 1
- Hypotension, often requiring fluid resuscitation or vasopressors 2
- Weakness, nausea, muscle/joint pain, and drowsiness that may develop rapidly 3
- Skin hyperpigmentation (in primary adrenal insufficiency) 4
Laboratory Abnormalities
- Electrolyte disturbances:
- Hyponatremia (low sodium)
- Hyperkalemia (high potassium) 2
- Hormonal changes:
Diagnostic Imaging Findings
CT Findings
- The "capsular sign" - a peripheral subtle hyperdense line around a hypodense enlarged adrenal gland
- This sign has 83% sensitivity, 100% specificity, and 93% diagnostic accuracy for adrenal ischemia 5
- Adrenal enlargement with minimal or no enhancement after contrast administration 4, 5
- Possible thrombosis of the main adrenal vein (found in 69% of adrenal ischemia cases) 5
MRI Findings
- Useful alternative when CT is contraindicated (e.g., in pregnancy) 6
- Can identify adrenal infarction without radiation exposure 6
Risk Factors and Predisposing Conditions
- Antiphospholipid syndrome 4
- COVID-19 infection 4
- Coagulopathy or elevated clotting factors (e.g., Factor VIII) 6
- Sepsis 1
- Adrenal tumors 1
- Abdominal trauma 1
Clinical Pitfalls and Considerations
- Diagnosis is challenging due to nonspecific clinical features 1
- Often discovered incidentally on imaging rather than through prospective clinical suspicion 1
- Bilateral adrenal infarction can lead to life-threatening adrenal crisis if not promptly recognized and treated 1
- In pregnant patients, diagnostic imaging may be limited due to concerns about fetal radiation exposure 6
- Symptoms may develop rapidly within hours, even in previously healthy individuals 3
Management Considerations
- Immediate parenteral hydrocortisone (100 mg bolus) followed by continuous infusion for suspected adrenal crisis 3
- Fluid resuscitation with normal saline (10-20 ml/kg; maximum 1,000 ml) 2
- Once hemorrhage is excluded, therapeutic anticoagulation should be considered to prevent progression or contralateral adrenal infarction 6
- Long-term hormone replacement therapy may be necessary with hydrocortisone 10-30 mg daily in divided doses (or equivalent prednisone 5-10 mg daily) 2
- Addition of mineralocorticoid replacement (fludrocortisone) once enteral feeding is established, particularly for primary adrenal insufficiency 2