A patient with an acute adrenal hemorrhage may present with a number of clinical findings. Diagnosis often requires imaging studies to demonstrate the hemorrhage.


Hemorrhage into the adrenal glands may be unilateral or bilateral. Adrenal insufficiency is possible if there is significant hemorrhage into both adrenal glands.


Clinical findings:

(1) acute flank pain

(2) nausea and vomiting

(3) hypotension

(4) palpable flank mass

(5) agitation and/or prostration

(6) costovertebral tenderness

(7) low grade fever (unless septic)


Laboratory values:

(1) may be normal

(2) may show adrenal insufficiency

(3) may show elevation or depression of free cortisol

(4) variable hyponatremia

(5) variable hyperkalemia

(6) hypoglycemia, which may be profound


Laboratory monitoring during and after the event should include plasma and urine testing for cortical and medullary function (cortisol, metanephrines, other) to detect adrenal insufficiency. Severe bilateral hemorrhage may result in adrenal insufficiency, which can be documented using the cosyntropin test


Findings on MRI during the acute phase (up to 7 days):

(1) one or both adrenals show a heterogeneous mass

(2) hyperintense on T2-weighted images

(3) isodense or slightly hyperintense with adjacent kidney on T1-weighted images


With time:

(1) the mass becomes hyperintense on the T1-weighted image

(2) a hypointense rim of hemosiderin may surround the resolving hematoma

(3) it is necessary to exclude an adrenal tumor that may require surgery


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