The most common cancer that metastasizes to the adrenal glands is lung cancer. Adrenal hemorrhage due to metastasis of lung cancer is extremely rare and associated with unilateral adrenal hemorrhage, while bilateral adrenal hemorrhages are typically associated with cardiovascular diseases and systemic anticoagulant therapy. Our 55-year-old male with a past medical history significant for metastatic lung adenocarcinoma and coronary artery disease (CAD) presented with acute right upper quadrant abdominal and flank pain. On presentation, patient was in distress, with fatigue, weakness, pain with deep inspiration, nausea, and vomiting. Patient also had anemia (hemoglobin 11.2). A CTA of the abdomen and pelvis showed a 10.7 x 5.9 cm right retroperitoneal hematoma in the region of the right adrenal gland with areas of enhancement on arterial phase imaging, consistent with a unilateral adrenal hemorrhage. He received morphine with improvement of his pain. The volume of the hematoma did not change significantly in size, prompting general surgery and interventional radiology to defer surgical intervention. The patient had a 1-year history of lung adenocarcinoma with adherence to his chemotherapy treatment (Osimertinib) and a 1-year history of CAD with adherence to his anticoagulant (rivaroxaban) and antiplatelet therapy (aspirin, clopidogrel). His anticoagulants, antiplatelet therapy, and chemotherapy were held during his admission. In patients with metastatic lung cancer that present with acute abdominal and flank pain with radiological confirmation of adrenal hemorrhage, an MRI is warranted to rule out adrenal metastasis. This patient’s anticoagulant therapy also increases his risk for developing adrenal hemorrhage, but evidence suggests that initiation of anticoagulant therapy increases the risk for bilateral adrenal hemorrhage, rather than unilateral adrenal hemorrhage. This case serves to alert the clinician of rare causes of unilateral adrenal hemorrhages. It also highlights the important of performing imaging such as CT scan and MRI to rule out adrenal metastasis in patients with lung cancer that present with acute abdominal or flank pain due to the poor prognosis associated with adrenal hemorrhage due to metastasis. Once adrenal metastasis is ruled out, more common causes can be considered on the differential, such as this patient’s use of anticoagulants.
Nasser B, Berghea R. A case of acute unilateral adrenal hemorrhage associated with metastatic lung adenocarcinoma. Presented at: The American College of Physicians Michigan Chapter Residents Day / Medical Students Day; 2022 May 13; Dearborn, MI.