Correspondence |
Bilateral adrenal haemorrhage and coeliac disease
Endocrine Unit Soroka Medical Center Faculty of Health Sciences Ben-Gurion University of the Negev Beer-Sheva Israel email: liel{at}bgu.ac.il
Sir,
Granel et al.1 describe an interesting case of bilateral adrenal haemorrage in a patient with an hypocoagulability state due to coeliac disease. The CT image presented in their report reveals: ‘asymmetrically enlarged adrenal glands ... with a heterogeneous appearance typical of adrenal haemorrhage’. This case is quite atypical, both from a clinical and radiological points of view. From the clinical perspective, there is a lack of evidence for adrenal insufficiency, including an unusually low serum potassium concentration (sodium was not reported). From the radiological perspective, a typical appearance of adrenal haemorrhage is characterized by high attenuation levels and retro-peritoneal involvement. The overall low attenuation level of the adrenal lesions in the present case, their well-defined circumscription and lack of retroperitoneal involvement are quite atypical of recent adrenal haemorrhages (suggested by the clinical presentation), but could still be compatible with so-called adrenal pseudocysts, characteristic of chronic, organizing, adrenal haematomas.2
References
1. Granel B, Rossi P, Frances Y, Henry J-F. Bilateral massive adrenal haemorrhage revealing coeliac disease. Q J Med 2005; 98:70–1.
2. Kawashima A, Sandler CM, Ernst RD, Takahashi N, Roubidoux MA, Goldman SM, Fishman EK, Dunnick NR. Imaging of Nontraumatic Hemorrhage of the Adrenal Gland. Radiographics 1999; 19:949–63.
Response
We thank Doctor Liel for the comment on our article concerning bilateral adrenal haemorrhage in the setting of coeliac disease.1 Ours is the first published case of bilateral adrenal haemorrhage due to haemorrhagic diathesis associated with coeliac disease. This case was clearly clinically complex, with underlying coagulopathy (a well-described cause of adrenal haemorrhage) and unexplained sub-acute back pain, which initially required morphine. Most of the time, the clinical findings seen in adrenal haemorrhage are non-specific.Faced with the severe cachexia and generally poor health of the patient, steroid repletion was given as soon as the diagnosis of adrenal haemorrhage was made, in the hopes of preventing death from acute adrenal crisis. Acute adrenal insufficiency associated with massive bilateral adrenal hemorrhage is not common, but it represents a life-threatening condition.2 It usually manifests clinically when 90% or more of each gland is destroyed.3 The lack of evidence for adrenal insufficiency in our patient (normal cortisol level and cosyntropin stimulation test) was surprising given the degree of radiographic abnormality of the adrenals, but might be explained by the short delay between diagnosis of adrenal haemorrhage and laboratory testing, as adrenal insufficiency could have developed subsequently. We suspect that the low serum potassium level observed in the case was related to the severe malabsorption syndrome and diarrhoea, due to long-standing coeliac disease, and thus does not preclude a diagnosis of adrenal insufficiency.
CT scan is the modality of choice for evaluation of adrenal haemorrhage. Non-traumatic haematoma characteristically appears round, and retroperitoneal involvement is not always seen. When the CT scan was reviewed by an expert (Professor J.-F. Henry), the diagnosis of adrenal haemorrhage was made; no better cause in the setting of haemorrhagic diathesis was identified. High attenuation levels, as mentioned by Doctor Liel, were observed in the adrenal glands on the non-enhanced CT scan. Moreover, radiographic abnormalities were present in the setting of back pain and coagulopathy and likely represent bleeding. Finally, serial radiological evaluation of the adrenal glands revealed a rapid decrease in their size and attenuation of the adrenals, which favours haematoma over adrenal pseudocyst.
Service de Médecine Interne Hôpital Nord
Service de Chirurgie générale et Endocrinienne Hôpital de la Timone Marseille France
References
1. Granel B, Rossi P, Frances Y, Henry J-F. Bilateral massive adrenal haemorrhage revealing coeliac disease. Q J Med 2005; 98:70–1.
2. Kawashima A, Sandler CM, Ernst RD, Takahashi N, Roubidoux MA, Goldman SM, Fishman EK, Dunnick NR. Imaging of Nontraumatic Hemorrhage of the Adrenal Gland. Radiographics 1999; 19:949–63.
3. Chin R. Adrenal crisis. Crit Care Clin 1991; 7:23–42.[Web of Science][Medline]
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