SAT-442 - Bilateral Adrenal Hemorrhage as A Rare Complication of Acute Myeloid Leukemia

Background:
Bilateral adrenal hemorrhage is a rare but life-threatening condition most commonly associated with trauma, anticoagulation, infection, or adrenal vein thrombosis. It is infrequently reported in acute myeloid leukemia (AML), in which thrombocytopenia, disseminated intravascular coagulation, and leukemic infiltration increase hemorrhagic risk. The adrenal glands’ vascular anatomy predisposes them to hemorrhage in hypercoagulable states. We report a case of acute myeloid leukemia initially presenting with unilateral adrenal involvement that progressed to bilateral adrenal hemorrhage and adrenal crisis.

Case:
A 53-year-old man presented with two days of abdominal pain. Blood pressure was 152/67 mmHg. Laboratory evaluation revealed a white blood cell count of 11.6 k/mm³ with 47% blasts, platelet count of 124 k/mm³, hemoglobin of 12.4 g/dL, and serum sodium of 132 mmol/L. Renal function, potassium, bicarbonate, and glucose were normal. Bone marrow biopsy confirmed AML, and chemotherapy including dexamethasone was initiated.
Computed tomography of the abdomen demonstrated a heterogeneous left adrenal mass measuring 3.0 × 2.7 × 4.2 cm. Magnetic resonance imaging showed a 4.2 cm non-enhancing left adrenal mass concerning for hemorrhage versus neoplasm. Initial cortisol level of 20.3 mcg/dL and aldosterone level of 9.7 ng/dL were normal, and plasma metanephrine levels were not consistent with pheochromocytoma.
During hospitalization, the patient developed worsening hyponatremia and hypotension. Repeat computed tomography of the abdomen obtained during evaluation for suspected sepsis revealed new bilateral adrenal hemorrhage. The platelet count had declined to 8 k/mm³. Cortisol measured three days after the last dose of dexamethasone was 1.7 mcg/dL, with undetectable aldosterone, confirming adrenal insufficiency. Stress-dose hydrocortisone (50 mg intravenously every six hours) resulted in rapid resolution of hypotension and hyponatremia. The patient was transitioned to physiological hydrocortisone dosing and started on fludrocortisone prior to discharge.

Conclusion:
Bilateral adrenal hemorrhage is a rare but life-threatening complication of AML, with only two cases previously reported in the literature. This case highlights the diagnostic challenge posed by initially unilateral disease and preserved adrenal function, with delayed progression to bilateral adrenal hemorrhage and adrenal crisis. A high index of suspicion is required for prompt recognition and treatment, particularly in patients with worsening cytopenias or hemodynamic instability.

*Unless otherwise noted, all abstracts presented at ENDO must not be released to the press or the public until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.*