Adrenal Hemorrhage: Waterhouse-Friderichsen

Adrenal hemorrhage is a rare but potentially fatal cause of acute adrenal insufficiency. Bilateral adrenal hemorrhage most commonly occurs in the setting of anticoagulation therapy (especially heparin-induced thrombocytopenia with thrombosis -- HIT), disseminated intravascular coagulation (DIC), sepsis (Waterhouse-Friderichsen syndrome -- fulminant meningococcemia causing bilateral adrenal hemorrhagic necrosis), antiphospholipid syndrome, major surgery, or severe physiological stress. The adrenal glands are particularly vulnerable to hemorrhage due to their rich arterial blood supply (three arteries) draining through a single central adrenal vein, creating a vascular dam effect where increased venous pressure during stress causes congestion and hemorrhage. Clinical presentation may be subtle or catastrophic: abdominal/flank/back pain, hypotension refractory to vasopressors, nausea/vomiting, fever, altered mental status, and hemodynamic collapse. The clinician maintains high clinical suspicion in patients on anticoagulants who develop unexplained hemodynamic instability or abdominal pain. Diagnosis: CT abdomen showing hyperdense adrenal glands (acute hemorrhage) or adrenal enlargement, random cortisol level (often inappropriately low for the degree of illness), and ACTH level. Treatment: immediate IV hydrocortisone 100 mg bolus then 50 mg every 6-8 hours, aggressive fluid resuscitation, correction of underlying coagulopathy, and...