Case Presentation: A 56-year-old male with history of alcohol abuse presented to the Emergency Room complaining of worsening abdominal pain for 2 weeks. Patient stated that he drinks half a pint of whiskey every day, and that the last drink was the day before presenting to the Emergency Room. He also reported that he had sustained a mechanical fall 2 weeks ago, sustaining an injury to the abdomen. Physical exam was positive for guarding and tenderness in left upper quadrant. Initial labs were normal except for a lipase of 140 units per liter (Normal range 10-99 Units per liter). CT scan of Abdomen revealed sub-capsular splenic, and perihepatic hematomas. On hospital day 3, the patient developed worsening abdominal pain, and delirium. Subsequent imaging revealed increase in the sizes of the hematomas. Patient was transferred to the ICU for closer monitoring. On hospital day 9, he was noted to have a sodium of 126 mmol per liter, rising potassium of 5.6 mmol per liter, orthostatic hypotension and his delirium continued to worsen. Attempts to correct fluid, and electrolyte abnormalities were only partially successful. Repeat CT Abdomen revealed stable splenic and perihepatic hematomas, and new bilateral adrenal hemorrhages. Adrenal insufficiency was confirmed with low serum Cortisol (1.9 microgram per deciliter), an ACTH-stimulation test; and significantly improved within 12 hours of steroid supplementation. He was later discharged on oral prednisone and Endocrine follow up.
Discussion: Delirium, an acute confusional state, occurs in 14-56% of hospitalized patients, with a higher incidence in geriatric populations and has been noted in about 42% of cases in Adrenal Hemorrhage (AH). In this case, what initially seemed to be alcohol withdrawal, followed by multifactorial delirium (including, but not limited to, alcohol withdrawal, pain, opiates, prolonged hospital stay), was revisited in the setting of refractory hyponatremia and orthostatic hypotension. The highly vascular adrenal gland has venous drainage through medullary sinusoids draining into the medullary vein. In critical illness, the increased catecholamine release causes venous constriction, thus causing an overflowing dam like physiology and predisposing to Adrenal Hemorrhage. Meningococcemia and infections from Staphylococcus have been associated with Adrenal Hemorrhage. Antiphospholipid Antibody syndrome and anticoagulation are known risk factors for Adrenal Hemorrhage. Adrenal hemorrhage leads to necrosis of the adrenal gland causing adrenal crisis which can present with hypotension, delirium, fevers or pain.
Conclusions: Adrenal hemorrhage/insufficiency should be suspected in cases of abdominal pain after anticoagulation, in the setting of refractory hyponatremia and as shown here, in refractory delirium. It is not an exaggeration to say that with advances in imaging, what used to be a diagnosis at autopsy previously, can now be diagnosed earlier, and is now completely treatable.