Isolated unilateral adrenal gland hemorrhage following motor vehicle collision: a case report and review of the literature

A 53-year-old white man presented to our emergency department for blunt trauma following a high-speed motor vehicle collision as a restrained driver (he was wearing a three-point seatbelt). His history included nephrolithiasis 3 years ago that resolved with conservative medical therapy. He denied any surgical history. He was not on any anticoagulant or antiplatelet therapy prior to trauma. His social history included daily tobacco use and negative for any drug use. A family history did not reveal any coagulation disorders. On presentation, he complained of mild right upper quadrant and right flank pain. An examination revealed mild tenderness to deep palpation in his right upper quadrant and right flank, without evidence of ecchymosis, hematoma, or lacerations on his abdomen or his chest. There were no other abnormal findings on physical examination or laboratory values (Tables 1, 2, 3, 4, 5 and 6). He had normal vital signs without evidence of hypotension or tachycardia: blood pressure 158/110 mmHg, pulse 86 beats/minute, and temperature 37 °C (98.6 °F).

A focused assessment with sonography for trauma (FAST) examination was performed in the emergency department and found to be negative, but owing to the high speeds involved in the crash, a computed tomography (CT) scan was subsequently ordered. The CT scan of his chest, abdomen, and pelvis revealed acute hemorrhage seen in the expected location of his right adrenal gland with an ovoid collection of increased density measuring 4.6 × 2.9 cm in size with periadrenal stranding and with blood tracking along the inferior margin of the right hepatic lobe (Fig. 1a). A normal right adrenal gland was not visualized due to the suspected hemorrhage in the area. The fluid seen on CT was consistent with blood product as opposed to adrenal mass. No other injuries were identified, specifically no injuries to his liver or kidneys. No rib or spine fractures were present.

He was admitted to our hospital for clinical observation and hemodynamic monitoring. His hemoglobin remained stable over 24 hours (Table 3). He had normal coagulation studies, as well as normal liver functions (Tables 4 and 5). He had slight elevation in his renal function with admission blood urea nitrogen (BUN) of 19 and creatinine (Cr) at 1.24. Repeat laboratory tests at 24 hours were normalized with BUN 14 and Cr 0.89. His urine analysis (UA) was clinically insignificant with trace amount of blood with 3/high-power field (HPF), rare bacteria, and it was negative for bilirubin, leukocyte esterase, and nitrites. A prior UA done in 2013 showed similar trace blood in urine secondary to left ureterolithiasis. He had no electrolyte abnormalities and had a stable 24 hours of vital signs; therefore, there was no clinical indication to continue further workup for possible adrenal dysfunction.

His clinical condition was stable with improvement in right upper quadrant and flank pain and tenderness. He was discharged from our hospital with restrictions on physical activities and he was asked to avoid anticoagulants. A follow-up repeat CT scan was scheduled to assess resolution of adrenal hematoma. Furthermore, because adrenal gland injury is not usually present in the absence of other injuries and his right adrenal gland was not visualized, occult neoplasm must be included in the differential diagnosis and required a follow-up.

At the 1-month follow-up a CT scan with intravenously and orally administered contrast for better delineation of surrounding structures was completed and showed the adrenal gland hemorrhage had improved and reduced to approximately 3.0 × 2.4 cm in diameter, and the previously noted right periadrenal fatty stranding was mostly resolved (Fig. 2a and b). Again, there were no other abnormal findings noted. During the 1-month clinical examination, he reported intermittent right upper quadrant pain that occurred approximately one to two times per week but he was back to his regular activities. A physical examination showed no abdominal or flank tenderness.

Due to persistent symptoms, he was instructed to follow-up in 3 months for another CT scan and examination. A 4-month CT scan was performed, which showed an improving appearance of right adrenal gland measuring maximally 1.2 cm transverse diameter and no other identifiable lesions (Fig. 3a and b). The time-dependent decrease in size of the right adrenal gland abnormality was consistent with hemorrhage, as opposed to adrenal neoplasm. He was asymptomatic at this time with resolution of abdominal pain and no symptoms of adrenal insufficiency.

The case of isolated adrenal gland injury presented here was unusual in that it involved a vehicle crash at high speeds, albeit without other injuries [3]. The presented case is not a new presentation but raises the question of how to follow hemorrhage of the adrenal gland without evidence of other organ injuries. Adrenal gland injuries are usually associated with other life-threatening injuries [1, 2, 12]. Accordingly, cases of isolated traumatic unilateral adrenal gland injuries are rare [3, 13‐15].

The AGT injury presented here shares a number of similarities with the few previously reported cases of isolated unilateral AGT [3, 13‐15]. Like most other cases of AGT, the major complaint in this case was abdomen pain in the right upper quadrant [3, 13‐15]. However, an unusual aspect of this case that differentiates it from other unilateral adrenal injuries is that the pain was mild; a failure to report the severity of pain may result in underreporting of this type of injury. Other reported isolated unilateral adrenal injuries presenting with severe pain were the result of sports injuries [3, 15].

In addition, the AGT observed here is similar to the other cases reporting similar injury with regard to its being unilateral and right sided [3, 7, 13, 15]. In a retrospective analysis of trauma patients, Mehrazin et al. found that a higher number of patients incurred right-sided adrenal gland injuries (that is, 78.5%); the authors hypothesized that this higher number of right-sided adrenal gland injuries could be explained by two potential mechanisms: compression of the adrenal gland by surrounding organs or the physiology of the right adrenal gland itself [7]. The higher frequency of right-sided trauma includes: acute rise in intra-adrenal venous pressure due to compression of the inferior vena cava (IVC) during impact; deceleration forces causing the small adrenal arterioles to shear; and crushing between the spine and surrounding organs [16].

Bilateral AGT can lead to life-threatening adrenal insufficiency or adrenal crisis, which without treatment can progress to cardiovascular collapse and severe sepsis [1, 2]. A high index of suspicion is required for hypotensive polytrauma patients with possible bilateral adrenal injuries [17]. Unlike bilateral AGT, unilateral AGT is normally a self-limited condition that can be managed with conservative treatment; however, due to the anatomic location, minor trauma to the adrenal gland can cause severe adrenal hemorrhage [6, 15, 18].

We reported here a rare case of isolated unilateral adrenal injury with hemorrhage from blunt trauma. The presence of adrenal neoplasm presenting as possible adrenal hemorrhage is described [19‐21]. The need to follow-up and to rule out an underlying adrenal neoplasm should be considered, due to possible hemorrhage into a pre-existing adrenal mass. Currently there are no guidelines for follow-up for an isolated traumatic adrenal hemorrhage and, if documented, resolution or absence of underlying neoplasm is required due to the rarity of these cases. The diagnostic challenge in this case is the necessary clinical and radiologic follow-up for isolated adrenal hemorrhage. We propose an interval CT follow-up at 1 to 4 months for large, > 4 cm, adrenal gland hemorrhage based on known likelihood of incidental adenomas < 4 cm, with typical radiologic findings, such as smooth and homogenous lesions, to have low risk of malignancy [22]. In further management, if adenoma cannot be ruled out, it may be beneficial to complete a biochemical analysis at the follow-up to rule out functioning adenomas.