What is the initial workup for a patient suspected of having adrenal infarction?

Initial Workup for Suspected Adrenal Infarction

The initial workup for a patient suspected of having adrenal infarction should include focused history and physical examination, non-contrast CT imaging, and comprehensive hormonal evaluation to assess for adrenal insufficiency. 1

Clinical Assessment

History - Key Elements to Assess:

• Risk factors for thrombotic events:
  • Antiphospholipid syndrome (common cause of adrenal infarction) 2, 3
  • COVID-19 infection (emerging association) 3
  • Coagulopathies
  • Recent surgery or anticoagulant therapy 4
• Symptoms of adrenal insufficiency:
  • Abdominal pain
  • Hypotension
  • Fatigue
  • Nausea/vomiting
  • Skin hyperpigmentation (in primary adrenal insufficiency)

Physical Examination - Key Findings:

• Vital signs with focus on hypotension
• Skin examination for hyperpigmentation
• Abdominal examination for tenderness
• Signs of hemodynamic instability

Imaging Studies

• First-line imaging: Non-contrast CT of the abdomen 1

  • Look for adrenal enlargement, hemorrhage, or infarction
  • Adrenal infarction may show enlarged glands with minimal peripheral enhancement after contrast
  • Bilateral involvement is common in autoimmune conditions like antiphospholipid syndrome

• Follow-up imaging: Consider contrast-enhanced CT if initial findings are indeterminate

  • Infarction typically shows lack of parenchymal enhancement with possible peripheral capsular enhancement 3

Laboratory Evaluation

Hormonal Assessment:

1. Adrenal function tests:

   • Morning serum cortisol (baseline)
   • ACTH level (elevated in primary adrenal insufficiency)
   • Synacthen (ACTH stimulation) test to confirm adrenal insufficiency 2
   • Aldosterone and renin levels

2. Electrolyte panel:

   • Sodium (typically low in adrenal insufficiency)
   • Potassium (typically elevated in primary adrenal insufficiency)
   • Glucose (may be low)

3. Additional hormonal workup if clinically indicated:

   • Dehydroepiandrosterone sulfate (DHEA-S)
   • Urinary catecholamines or metanephrines (to rule out pheochromocytoma) 1

Coagulation and Autoimmune Workup:

• Antiphospholipid antibodies (cardiolipin antibodies, lupus anticoagulant) 3
• Coagulation profile (PT, PTT, INR)
• Complete blood count
• Inflammatory markers (ESR, CRP)

Management of Suspected Adrenal Crisis

If adrenal insufficiency is suspected during workup:

• Immediate administration of hydrocortisone 100 mg IV 5
• Fluid resuscitation with normal saline (10-20 ml/kg; maximum 1,000 ml) 5
• Consider continuous hydrocortisone infusion of 200 mg/24h until stabilized 5

Multidisciplinary Approach

• Involve endocrinology early in the diagnostic process
• Consider vascular surgery consultation if intervention might be needed
• Hematology consultation if underlying coagulopathy is suspected 1

Common Pitfalls to Avoid

• Delaying glucocorticoid treatment when adrenal insufficiency is suspected
• Failing to consider antiphospholipid syndrome as an underlying cause
• Missing bilateral involvement (which carries higher risk of adrenal insufficiency)
• Overlooking adrenal infarction in patients with unexplained abdominal pain and hypotension, especially with risk factors 6

Remember that adrenal infarction is often underdiagnosed due to its nonspecific presentation. A high index of suspicion is necessary, particularly in patients with predisposing conditions such as antiphospholipid syndrome or COVID-19 infection.