We present two cases of traumatic adrenal haemorrhage resulting in hypocortisolism, with different presentations and outcomes, highlighting the need to consider adrenal failure in trauma patients.
Case 1: A 60-year-old man presented following a high-speed motor vehicle accident (MVA). Initial trauma CT demonstrated hepatic and bilateral adrenal haemorrhages. He had significant haemodynamic instability and was commenced on intravenous hydrocortisone. The 8AM cortisol on day six, after withholding hydrocortisone the prior afternoon, was 57 nmol/L (100-540 nmol/L) with an associated rise in noradrenaline requirements. Over the next ten days, hydrocortisone was weaned to an oral replacement dose. Two weeks later, after withholding the afternoon hydrocortisone, the 8 AM cortisol was 533 nmol/L with ACTH 34 pg/ml (<46 pg/ml) and hydrocortisone was ceased. Follow-up CT scan four months later demonstrated resolution of the adrenal haemorrhages, but a persisting 20 x 22 mm low density mass (5-13 Hounsfield units (HU)), within the left adrenal gland consistent with an adenoma.
Case 2: An 88-year-old woman on dabigatran for atrial fibrillation presented following a high-speed MVA, sustaining multiple fractures, a left-sided subdural haematoma and a subcapsular splenic haematoma. Initial trauma CT did not demonstrate any adrenal injury. She was haemodynamically stable throughout her week-long admission and was discharged to rehabilitation. Three days later, she became significantly hypotensive and was readmitted for vasopressor support. Repeat abdominal CT demonstrated new bilateral adrenal haemorrhages. Serum cortisol was <28 nmol/L and she was commenced on intravenous hydrocortisone. Persisting primary adrenal insufficiency was confirmed one week later, with 8 AM cortisol 129 nmol/L and ACTH 82 ng/L. Intravenous hydrocortisone was weaned to an oral replacement dose. Repeat CT scan four months later demonstrated complete resolution of the adrenal haemorrhages. However, she has persisting adrenal insufficiency, with 8 AM cortisol 43 nmol/L and ACTH 66.2 pmol/L and remains on hydrocortisone replacement.