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 with suspected adrenal infarction should include focused history and physical examination, non-contrast CT imaging of the adrenal glands, and comprehensive hormonal evaluation to assess for adrenal insufficiency and rule out other adrenal pathologies. 1

Clinical Assessment

History - Key Elements to Assess:

• Risk factors for thrombosis (antiphospholipid syndrome, COVID-19 infection) 2, 3
• Abdominal pain (often acute and severe)
• Symptoms of adrenal insufficiency:
  • Fatigue, weakness
  • Hypotension or orthostatic symptoms
  • Nausea, vomiting
  • Weight loss
  • Salt craving
• Recent trauma, surgery, or anticoagulant therapy 4
• History of autoimmune disorders

Physical Examination - Key Findings:

• Hypotension (may be severe in adrenal crisis)
• Skin hyperpigmentation (in primary adrenal insufficiency) 3
• Fever or hypothermia 5
• Abdominal tenderness
• Signs of dehydration

Diagnostic Testing

Immediate Laboratory Tests:

• Serum cortisol (early morning, preferably before 9 AM)
• ACTH level (to differentiate primary vs. secondary adrenal insufficiency) 5
• Electrolytes (look for hyponatremia, hyperkalemia) 5
• Complete blood count
• Coagulation profile
• Inflammatory markers (ESR, CRP)
• Antiphospholipid antibodies (if suspected) 3

Hormonal Workup:

1. Adrenal Insufficiency Assessment:

   • ACTH stimulation test (standard or low-dose) 5, 6
   • Baseline and stimulated cortisol levels

2. Additional Hormonal Testing: 1

   • Aldosterone and renin levels
   • Plasma metanephrines and normetanephrines
   • DHEA-S
   • Androstenedione, testosterone (especially in females)
   • 24-hour urinary steroid metabolite examination

Imaging:

• Non-contrast CT scan of the abdomen (first-line imaging) 1
  • Look for adrenal enlargement, hemorrhage, or lack of enhancement
  • Hounsfield Units (HU) measurement (>10 HU suggests non-adenoma)
• Contrast-enhanced CT if initial CT is indeterminate
  • Lack of enhancement suggests infarction 3
• MRI may be considered as an alternative or complementary test

Management Considerations

Immediate Management:

• If adrenal insufficiency is suspected, do not delay treatment while awaiting test results:
  • Hydrocortisone 100 mg IV immediately 5
  • Fluid resuscitation with normal saline (10-20 ml/kg) 5
  • Continuous hydrocortisone infusion (200 mg/24h) until stabilized 5

Multidisciplinary Approach:

• Early consultation with endocrinology
• Consider vascular surgery or interventional radiology consultation
• Low threshold for multidisciplinary review by endocrinologists, surgeons, and radiologists 1

Special Considerations

• Bilateral adrenal infarction is more likely to cause adrenal insufficiency than unilateral infarction 2
• Antiphospholipid syndrome is a significant risk factor for adrenal infarction 2, 4, 3
• COVID-19 infection has been associated with adrenal infarction, particularly in patients with antiphospholipid antibodies 3
• Adrenal insufficiency due to infarction may be permanent in most cases, but partial recovery has been reported in rare instances 2

Pitfalls to Avoid

• Delaying glucocorticoid treatment when adrenal insufficiency is suspected
• Failing to consider adrenal infarction in patients with unexplained abdominal pain and hypotension, especially with risk factors
• Overlooking the need for both glucocorticoid and mineralocorticoid replacement in confirmed primary adrenal insufficiency
• Misinterpreting imaging findings (adrenal infarction can be confused with other adrenal pathologies)