Spontaneous Bilateral Adrenal Hemorrhage

Background

Adrenal hemorrhage is a rare condition that results in adrenal shock, death, or adrenal crisis unless treated on time (Dahiya et al. 2). Unfortunately, the symptoms of the disease are not easy to identify because they are unclear. In fact, most patients discover that they are suffering from this disease when being scanned for other cases. Since it does not have any clinical manifestations, it is difficult to point out the causes or effectively treat it (Barucha et al. 6). In adults, the disease is caused by sepsis from an organism or meningococcemia. In addition, being under extreme stress could lead to insufficient production of adrenaline which may cause the disease.

Pathophysiology

The pathophysiology of this disease remains unclear. However, there are features which predispose the adrenal medulla to thrombosis (Sharma 12). It is important to note that thrombosis has been linked to this disease. Regarding the features, the rich supply of blood from the artery to the delicate subscapular arteries with very few venules is the major contributor (Girgis et al. 44). The adrenal gland has arich supply of blood but has poor drainage because it depends on one vein. In the same manner, stressful conditions also lead to the disease as mentioned earlier. In the adrenal glands, there is a hormone called adrenocorticotropic (ACTH) whose quantity increases when an individual is stressed (Rosenberger et al. 31). ACTH has the effect of making arterial blood flow into the arteries much higher than the vein can drain. Coupled with thrombosis, the likelihood of this disease occurring are much higher.

The occurrence of the disease is attributed to a disease called Waterhouse “Friedrich en syndrome (WFS). This disease leads to the failure of the adrenal glands due to excessive bleeding into the adrenal glands (Hammond et al. 2,476). The pathogen responsible for this disease is called meningococcus. A bacterial infection leads to meningococcemia which causes the severe bleeding. Even though WFS is classically named as the main cause, bilateral hemorrhage can occur due to pregnancy, burns, and traumatic events (Hammond et al. 2,477).

Other adrenal diseases or complications are also associated with the disease. For instance, thrombocytopenia or surgery.

Epidemiology

Frequency

The occurrence of this disease is very rare. As a matter of fact, it was assumed that less than 1% of the total population had the disease several decades ago. In America, less between 0.3 and 1.8 % of the population suffers from the disease (Sharma 14). Even so, for people who die of shock, 15% of them are believed to have suffered from this disease.

Mortality

Acute adrenal insufficiency may occur in the presence of the disease. Surprisingly, patients who suffer from adrenal hemorrhage do so because of underlying diseases related to the adrenal glands (Sacerdote 55). That is to say, even when treatment is successful, there is still the possibility of the patient dying. In general, this disease accounts for 15% of the total mortality of people suffering from adrenal problems. Despite that, it is possible for the severity to increase depending on the underlying adrenal disease (Bharucha 13). To illustrate, patients suffering from WFS have higher mortality rates than those who have less threatening diseases. To be precise, these patients have a 50-60% mortality rate.Chronic adrenal insufficiency occurs in people who survive from this disease. For their recovery, they require long-term glucocorticoid replacement.

Androgen replacement is also available as an alternative form of treatment (Dahiya 7). Despite the treatment options, there are very rare cases of patients recovering completely. Nevertheless, early treatment and detection make all the difference.

Gender factors

According to reports, males have a higher chance of getting the bilateral hemorrhage than females. The ratio of man to woman is 2:1 (Dahiya 8). That means that men are twice as likely to get this disease as women.

Age

Although age is not a prime factor, it has been reported that people affected by this disease are in their thirties at the very least (Rosenberger 35). Furthermore, the people in their 40s have higher chances of getting this disease.

Although traumatic experiences could lead to the disease, non-traumatic causes are also responsible for it. By the age, 80% the likelihood of getting this disease is much higher. WFS is a pediatric disease that increases one’s chance of getting the disease.

Signs and symptoms

As mentioned earlier, the disease does not have any distinctive signs and symptoms to enhance treatment. Even so, there are several characteristics that have been identified in the patients. They include:

Primary symptoms

The primary symptoms of this disease are chest pain or in other cases back pain, and pain in the abdomen. Fever may occur although it is a rare feature (Hammond 2,485). In the case of theabdomen, acute abdominal rigidity and rebound tenderness were reported in 15%-20% of the cases. Hypotension may also occur though the chances are 15%. In Severe but rare cases, anemia may occur. As noted, these symptoms are not isolated in occurrence. In light of that, pinpointing the actual disease becomes problematic (Dahiya 9). In the case of pregnant women, it is even worse because of similar symptoms arising from other factors. As aforementioned, chances of survival of this disease are very low.

Diagnosis

CT scansThe standard diagnostic measure includes the use of computed tomography (CT) scans with or without contrast. The CT scan is important because, through it, the adrenaline gland can clearly be seen and so can any swellings in it (Hammond et al. 2,499). A CT scan also helps differentiate the different causes of the hemorrhage. Through this clarity, the doctor can tell the different causes of the bleeding. The differentiation is obtained through enhancing the images and precontrast scans (Girgis 50). CT scans are more a more popular approach to diagnosing this disease. However, the rim enhancement makes it difficult to tell the precise cause of the hemorrhage.

MRI scans

Magnetic Resonance Imaging (MRI) scans are believed to be more accurate than CT scans. MRI scans with contrast enhanced with subtraction imaging give more accurate results (Sacerdote 57). In MRI scans, methemoglobin is used to detect and enhance areas of high signal on unenhanced T- weighted sequences. This aspect presents a problem because it makes it difficult to differentiate. To counter this problem, the subtraction of any particles in the blood is done. What is left is a hematoma which is identified (Sacerdote 59). MRI is the best alternative because it differentiates the acute and sub-acute hemorrhages. The two methods of diagnosis are commonly used in hospitals because they point out any unusual occurrence within the adrenaline glands (Bharucha 24).

Diagnosis is important because it is the first step toward a treatment plan that could reduce chances of death. TreatmentThe treatment of this disease includes therapy sessions to replace the functioning of the adrenal glands and reduce any excessive fluids. In nontraumatic cases, surgery is not required. On the other hand, traumatic causes require surgery (Sharma 35). Treatment in children is done with parental guidance. Hydrocortisone is administered to children. Other drugs include Mineralocorticoids though this may not be effective in the case of bilateral hemorrhage in the long run. Radiology may also come in handy.

Diet

For individuals suffering from this disease, a lot of water and salt intake is important. For those critically ill, they are kept on a status called nothing by mouth (NPO) (Bharucha et al. 33). The NPO status is given depending on the severity of symptoms such as vomiting. Bed rest is required for those people suffering from this disease.

Patient counseling and education

Patient counseling and education are given to enable the patients to help them understand their condition better. For clarification, the patients visit several specialists who take part in their treatment process (Sacerdote 65). They include an endocrinologist who educates them more about the role that hormones play in the disease and how to manage it. Another consultant is a urologist or at times a surgeon who may or may not perform surgery on the patient. A cardiologist may also come in handy. Other specialists may such as infectious disease specialists are included in helping the patient manage the disease.

Conclusion

To conclude, it is evident that the disease is not easy to identify because some of the symptoms resemble those of other diseases. This disease is relatively rare and so not so much literature is available. This can be seen in the case of its pathology. Through CT and MRI scans, it is possible to identify the hemorrhage in the adrenal glands. While treatment is effective, there is still a high level of mortality rates experienced. Even so, it is important for the age groups susceptible to this disease to be checked should any of the symptoms suffice.

Works cited

Anagnostopoulos, A., and S. Sharma. “Spontaneous adrenal hemorrhage in pregnancy.” BMJ case reports 2011 (2011): bcr0720114496.Bharucha, Tehmina, et al. “Bilateral adrenal hemorrhage presenting as epigastric and back pain.” JRSM short reports 3.3 (2012): 1-40.Dahiya, Saurabh, Anju Bhagavan, and Wei Boon Ooi. “Spontaneous bilateral adrenal hemorrhage.” Endocrine (2012): 1-30.Girgis, Christian M., Louise Cole, and Bernard L. Champion. “Bilateral adrenal haemorrhage in a critically ill patient.” Critical Care and Resuscitation 13.2 (2011): 123.Hammond, Nancy A., et al. “Imaging of adrenal and renal hemorrhage.” Abdominal Imaging 40.7 (2015): 2747-2760.Rosenberger, Laura H., et al. “Bilateral adrenal hemorrhage: the unrecognized cause of hemodynamic collapse associated with heparin-induced thrombocytopenia.” Critical care medicine 39.4 (2011): 833.Sacerdote, Michael G., Pamela T. Johnson, and Elliot K. Fishman. “CT of the adrenal gland: the many faces of adrenal hemorrhage.” Emergency Radiology 19.1 (2012): 53-70.

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