Abstract
Non-traumatic adrenal crisis is a rare but critical diagnosis to make in emergency settings due to grave consequences. Various pathologies can present as acute crisis, such as spectrum of endocrine imbalance, ranging from catecholamine excess in pheochromocytomas to acute adrenal insufficiency related to glandular dysfunction. Critical manifestations may be due to structural causes related to adrenal hemorrhage, especially when they are bilateral. Oncological complications such as vascular invasion, tumoral bleed, rupture, and hormonal dysfunction can occur. Due to non-specific clinical presentation, these conditions may come as a surprise on imaging performed for other reasons. Recognition of these imaging findings is critical for appropriate patient management. Although there are few articles discussing non-traumatic emergencies in literature, this review is inclusive of all possible etiologies, thus provides a holistic approach and insight into each situation. Specific imaging approach is needed to tailor the diagnosis. This article will also discuss about the advanced imaging techniques that will complement diagnosis.
Similar content being viewed by others
References
Chernyak V, Patlas MN, Menias CO, Soto JA, Kielar AZ, Rozenblit AM, Romano L, Katz DS (2015) Traumatic and non-traumatic adrenal emergencies. Emerg Radiol 22:697–704
Sacerdote MG, Johnson PT, Fishman EK (2012) CT of the adrenal gland: the many faces of adrenal hemorrhage. Emerg Radiol 19:53–60
Baccot S, Tiffet O, Bonnot P (2000) Bilateral post-traumatic adrenal hemorrhage: report of a case with acute adrenal insufficiency. Ann Chir 125:273
Mehrazin R, Derweesh IH, Kincade MC (2007) Adrenal trauma: Elvis Presley Memorial Trauma Center experience. Urology. 70:851–855
Jordan E, Poder L, Courtier J, Sai V, Jung A, Coakley FV (2012) Imaging of nontraumatic adrenal hemorrhage. AJR Am J Roentgenol 199:W91–W98
Kawashima A, Sandler CM, Ernst RD, Takahashi N, Roubidoux MA, Goldman SM, Fishman EK, Dunnick NR (1999) Imaging of nontraumatic hemorrhage of the adrenal gland. Radiographics. 19:949–963
Rana AI, Kenney PJ, Lockhart ME, McGwin G Jr, Morgan DE, Windham ST 3rd, Smith JK (2004) Adrenal gland hematomas in trauma patients. Radiology 230:669–675
Velaphi SC, Perlman JM (2001) Neonatal adrenal hemorrhage: clinical and abdominal sonographic findings. Clin Pediatr 40(10):545–548
Westra SJ, Zaninovic AC, Hall TR, Kangarloo H, Boechat MI (1994) Imaging of the adrenal gland in children. RadioGraphics 14:1323–1340
Mutlu M, Karaguzel G, Aslan Y, Cansu A, Okten A (2011) Adrenal hemorrhage in newborns: a retrospective study. World J Pediatr 7:355–357
Eo H, Kim JH, Jang KM, Yoo SY, Lim GY, Kim MJ, Kim OH (2011) Comparison of clinico-radiological features between congenital cystic neuroblastoma and neonatal adrenal hemorrhagic pseudocyst. Korean J Radiol 12:52–58
Brodeur GM, Bagatell R (2014) Mechanisms of neuroblastoma regression. Nat Rev Clin Oncol 11:704–713
Paolo WF Jr, Nosanchuk JD (2006) Adrenal infections. Int J Infect Dis 10:343–353
Lattin GE Jr, Sturgill ED, Tujo CA, Marko J, Sanchez-Maldonado KW, Craig WD, Lack EE (2014) From the radiologic pathology archives: adrenal tumors and tumor-like conditions in the adult: radiologic-pathologic correlation. Radiographics. 34:805–829
Saad AF, Ford KL 3rd, Deprisco G, Smerud MJ (2013) Adrenomegaly and septic adrenal hemorrhage (Waterhouse-Friderichsen syndrome) in the setting of congenital adrenal hyperplasia. Proc (Baylor Univ Med Cent) 26:268–269
Varon J, Chen K, Sternbach GL (1998) Rupert Waterhouse and Carl Friderichsen: adrenal apoplexy. J Emerg Med 16:643–647
Lam KY, Lo CY (2001) A critical examination of adrenal tuberculosis and a 28-year autopsy experience of active tuberculosis. Clin Endocrinol 54:633–639
Huang YC, Tang YL, Zhang XM, Zeng NL, Li R, Chen TW (2015) Evaluation of primary adrenal insufficiency secondary to tuberculous adrenalitis with computed tomography and magnetic resonance imaging: current status. World J Radiol 7:336–342
Guo YK, Yang ZG, Li Y, Ma ES, Deng YP, Min PQ, Yin LL, Hu J, Zhang XC, Chen TW (2007) Addison’s disease due to adrenal tuberculosis: contrast-enhanced CT features and clinical duration correlation. Eur J Radiol 62:126–131
Zhang XC, Yang ZG, Li Y, Min PQ, Guo YK, Deng YP, Dong ZH (2008) Addison’s disease due to adrenal tuberculosis: MRI features. Abdom Imaging 33:689–694
Young WF (2007) Primary aldosteronism: renaissance of a syndrome. Clin Endocrinol 66:607–618
Vyas S, Kalra N, Das PJ, Lal A, Radhika S, Bhansali A, Khandelwal N (2011) Adrenal histoplasmosis: an unusual cause of adrenomegaly. Indian J Nephrol 21:283–285
Sarosi GA, Voth DW, Dahl BA, Doto IL, Tosh FE (1971) Disseminated histoplasmosis: results of long-term follow-up. A center for disease control cooperative mycoses study. Ann Intern Med 75:511–516
Kawashima A, Sandler CM, Fishman EK, Charnsangavej C, Yasumori K, Honda H, Ernst RD, Takahashi N, Raval BK, Masuda K, Goldman SM (1998) Spectrum of CT findings in nonmalignant disease of the adrenal gland. Radiographics. 18:393–412
Kumar N, Singh S, Govil S (2003) Adrenal histoplasmosis: clinical presentation and imaging features in nine cases. Abdom Imaging 28:703–708
Radin DR (1991) Disseminated histoplasmosis: abdominal CT findings in 16 patients. AJR Am J Roentgenol 157:955–958
Wilson DA, Muchmore HG, Tisdal RG, Fahmy A, Pitha JV (1984) Histoplasmosis of the adrenal glands studied by CT. Radiology. 150:779–783
Bittman ME, Lee EY, Restrepo R, Eisenberg RL (2013) Focal adrenal lesions in pediatric patients. AJR Am J Roentgenol 200:W542–W556
Berland LL, Silverman SG, Gore RM, Mayo-Smith WW, Megibow AJ, Yee J, Brink JA, Baker ME, Federle MP, Foley WD, Francis IR, Herts BR, Israel GM, Krinsky G, Platt JF, Shuman WP, Taylor AJ (2010) Managing incidental findings on abdominal CT: white paper of the ACR incidental findings committee. J Am Coll Radiol 7:754–773
Arnold DT, Reed JB, Burt K (2003) Evaluation and management of the incidental adrenal mass. Proc (Bayl Univ Med Cent) 16:7–12
Chin R (1991) Adrenal crisis. Crit Care Clin 7:23–42
Leung K, Stamm M, Raja A, Low G (2013) Pheochromocytoma: the range of appearances on ultrasound, CT, MRI, and functional imaging. AJR Am J Roentgenol 200:370–378
Bravo EL, Gifford RW (1984) Current concepts: pheochromocytoma—diagnosis, localization and management. N Engl J Med 311:1298–1303
Terzolo M, Stigliano A, Chiodini I, Loli P, Furlani L, Arnaldi G, Reimondo G, Pia A, Toscano V, Zini M, Borretta G, Papini E, Garofalo P, Allolio B, Dupas B, Mantero F, Tabarin A, Italian Association of Clinical Endocrinologists (2011) AME position statement on adrenal incidentaloma. Eur J Endocrinol 164:851–870
Blake MA, Kalra MK, Maher MM, Sahani DV, Sweeney AT, Mueller PR, Hahn PF, Boland GW (2004) Pheochromocytoma: an imaging chameleon. Radiographics. 24(Suppl 1):S87–S99
Beierwaltes WH (1991) Endocrine imaging: parathyroid, adrenal cortex and medulla, and other endocrine tumors: part II. J Nucl Med 32:1627–1639
Hoeffel C, Legmann P, Luton JP, Chapuis Y, Fayet-Boynnin P (1995) Spontaneous unilateral adrenal hemorrhage: computerized tomography and magnetic resonance imaging findings in 8 cases. J Urol 154:1647–1651
Russell C, Goodacre BW, van Sonnenberg E, Orihuela E (2000) Spontaneous rupture of adrenal myelolipoma: spiral CT appearance. Abdom Imaging 25:431–434
Kenney PJ, Wagner BJ, Rao P, Heffess CS (1998) Myelolipoma: CT and pathologic features. Radiology 208:87–95
Hamrick-Turner JE, Abbitt PL, Allen BC, Fowler JE Jr, Cranston PE, Harrison RB (1993) Adrenal hemangioma: MR findings with pathologic correlation. J Comput Assist Tomogr 17:503–505
Xu HX, Liu GJ (2003) Huge cavernous hemangioma of the adrenal gland: sonographic, computed tomographic, and magnetic resonance imaging findings. J Ultrasound Med 22:523–526
Outwater E, Bankoff MS (1989) Clinically significant adrenal hemorrhage secondary to metastases: computed tomographic observations. Clin Imaging 13:195–200
Chiche L, Dousset B, Kieffer E, Chapuis Y (2006) Adrenocortical carcinoma extending into the inferior vena cava: presentation of a 15-patient series and review of the literature. Surgery. 139:15–27
Sandrasegaran K, Patel AA, Ramaswamy R, Samuel VP, Northcutt BG, Frank MS, Francis IR (2011) Characterization of adrenal masses with diffusion-weighted imaging. AJR Am J Roentgenol 197:132–138
Inan N, Arslan A, Akansel G, Anik Y, Balci NC, Demirci A (2008) Dynamic contrast enhanced MRI in the differential diagnosis of adrenal adenomas and malignant adrenal masses. Eur J Radiol 65:154–162
Malayeri AA, Zaheer A, Fishman EK, Macura KJ (2013) Adrenal masses: contemporary imaging characterization. J Comput Assist Tomogr 37:528–542
Faria JF, Goldman SM, Szejnfeld J, Melo H, Kater C, Kenney P, Huayllas MP, Demarchi G, Francisco VV, Andreoni C, Srougi M, Ortiz V, Abdalla N (2007) Adrenal masses: characterization with in vivo proton MR spectroscopy—initial experience. Radiology. 245:788–797
Acknowledgments
Our patients, the great source of learning.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no conflict of interest.
Additional information
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Nepal, P., Ojili, V., Tirumani, S. et al. A pictorial review of non-traumatic adrenergic crisis. Emerg Radiol 27, 533–545 (2020). https://doi.org/10.1007/s10140-020-01777-2
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10140-020-01777-2