Bilateral massive adrenal hemorrhage.

A systematic review of the etiopathogenesis of adrenal hemorrhage reveals that the factors that determine the occurrence of this complication in a patient can be identified prospectively. Such prospective diagnostic suspicion allows the significance of the otherwise nonspecific clinical features heralding this catastrophe to be appreciated in the precrisis interval. Confirmation of the diagnosis is achieved by visual demonstration of bilaterally enlarged and hyperdense adrenal glands on a CT scan and by demonstration of adrenocortical failure on hormonal evaluation. Preemptive steroid therapy and diagnostic evaluation during the precrisis period prevent the occurrence of a potentially disastrous adrenal crisis in a patient who is seriously ill from other problems and who cannot afford a setback of this severity. Because steroid therapy delayed until the stage of crisis may be unsuccessful in salvaging such a patient, prospective recognition must be based on identifying the patient at risk for BMAH and recognizing the significance of the nonspecific clinical features that accompany it in the appropriate clinical context.