Rapid recovery from adrenal insufficiency due to bilateral adrenal hemorrhage

Most patients with adrenal insufficiency require lifelong glucocorticoid or glucocorticoid and mineralocorticoid replacement. Feuerstein and Streeten [1] first reported complete recovery of adrenal function in a patient with adrenal insufficiency after post-traumatic bilateral adrenal hemorrhage. We report a patient who rapidly recovered from adrenal insufficiency associated with post-operative anticoagulant-induced bilateral adrenal hemorrhage. A 35-year-old white male in excellent health sustained major left facial, rib, and pelvic trauma in a tractor accident. After surgical repair of pelvic fractures he was prophylactically anticoagulated with low-dose coumadin. Seven days later he developed subacute onset of fatigue, nausea, lightheadedness, generalized weakness, and decreased mentation. Supine blood pressure, pulse, serum electrolytes, glucose, and his prothrombin time were normal. CT scan of his abdomen revealed bilateral adrenal enlargement, and MRI scan T2-weighted images were consistent with the presence of adrenal fluid. His baseline 9 a.m. cortisol was 4.6 μg/dL (normal, 7–25) and failed to rise with cosyntropin (synthetic ACTH 1–24) stimulation. CT-guided right adrenal gland fine-needle aspiration revealed hemorrhagic fluid. Hydrocortisone sodium succinate 300 mg/day IV resulted in marked improvement within 24 hours. Nine months later he completely discontinued cortisol replacement without adverse effect. This case illustrates that patients with adrenal insufficiency due to bilateral adrenal hemorrhage may rapidly recover adrenal function.