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Bilateral Massive Adrenal Hemorrhage: Early Recognition and Treatment

R. Harsha Rao, MD; Anthony H. Vagnucci, MD; and Janet A. Amico, MD
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Requests for Reprints: R. Harsha Rao, MD, Montefiore Hospital, Department of Medicine, 3459 Fifth Avenue, Pittsburgh, PA 15213.

Current Author Addresses: Drs. Rao and Vagnucci: Montefiore Hospital, Department of Medicine, 3459 Fifth Avenue, Pittsburgh, PA 15213. Dr. Amico: 930 Scaife Hall, Division of Endocrinology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261.

© 1989 American College of PhysiciansAmerican College of Physicians

Ann Intern Med. 1989;110(3):227-235. doi:10.7326/0003-4819-110-3-227
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Purpose: To develop a clinical perspective on bilateral massive adrenal hemorrhage and an algorithm for its diagnosis and treatment.

Data Identification: Case reports were identified through a computer search using MEDLINE (1976 to 1987), and from bibliographies in review articles (up to 1978).

Study Selection: Twelve reports published since 1978 were found.

Data Extraction: Data from 20 recently reported cases and 5 cases from personal records were compared with data from 142 previously reported, autopsy-proven cases summarized in a 1978 review article.

Results of Data Analysis: Thromboembolic disease, coagulopathy, and the postoperative state were the three major risk factors. Except for abdominal pain and remittent fever, clinical features were not helpful in diagnosis. A fall in hemoglobin, and progressive biochemical hypoadrenalism were important clues. Diagnosis was confirmed by computed tomography and an absent cortisol response to intravenous corticotropin. Long-term follow-up showed complete atrophy and functional failure of the adrenal gland.

Conclusions: Death from bilateral massive adrenal hemorrhage can be prevented by pre-emptive steroid therapy in high-risk patients who have certain clinical and laboratory features.





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