Adrenal Hemorrhage / Calcification
Adrenal hemorrhage is bleeding into one or both adrenal glands, small hormone-producing glands that sit on top of the kidneys. It can result from trauma, severe infection, blood clotting disorders, anticoagulation, complications of pregnancy or surgery, and other causes. Adrenal calcification is the presence of calcium deposits within the adrenal glands, often the long-term consequence of prior hemorrhage, infection (such as tuberculosis or histoplasmosis), or inflammation. Many cases are asymptomatic and identified incidentally on imaging, but adrenal hemorrhage can be a medical emergency when severe or when it affects both adrenal glands. Imaging—particularly CT and MRI—is central to diagnosis.
What is it?
The adrenal glands are two small triangular organs that sit on top of the kidneys. They produce several important hormones, including cortisol (which helps the body respond to stress and regulates metabolism, blood pressure, and immune function), aldosterone (which regulates sodium, potassium, and blood pressure), and adrenaline and noradrenaline (which help the body respond to acute stress). The adrenal glands are highly vascular, with a rich blood supply from multiple small arteries.
Adrenal hemorrhage is bleeding into one or both adrenal glands. It can range from small, self-limited bleeds identified incidentally on imaging to massive hemorrhages that severely damage the glands and produce life-threatening adrenal insufficiency. Adrenal calcification is the presence of calcium deposits within the adrenal glands and often represents the long-term consequence of prior hemorrhage, infection, or inflammation. Together, adrenal hemorrhage and calcification are discussed as a spectrum because they often reflect the same underlying processes at different stages.
The causes of adrenal hemorrhage are diverse. Trauma to the abdomen or back—including motor vehicle accidents, falls, and sports injuries—is one of the most common causes, particularly on the right side because of the anatomy of the right adrenal vein. Severe infection with sepsis, particularly meningococcemia (the classic “Waterhouse-Friderichsen syndrome”), can produce dramatic bilateral adrenal hemorrhage. Anticoagulation therapy (such as heparin or warfarin) and inherited or acquired clotting disorders (such as antiphospholipid syndrome or heparin-induced thrombocytopenia) are important risk factors. Complications of pregnancy, childbirth, and surgery can also lead to adrenal hemorrhage. Newborns, particularly after difficult births, may develop adrenal hemorrhage that is often identified by ultrasound. Adrenal tumors, both benign and malignant (including pheochromocytoma, adrenal cortical carcinoma, and adrenal metastases), can bleed into themselves. Less commonly, adrenal hemorrhage can occur without an identified cause.
Adrenal calcification, in turn, can result from many of the same conditions that cause hemorrhage, as well as from prior infections (such as tuberculosis, histoplasmosis, or other granulomatous diseases), Wolman disease (a rare inherited storage disorder), certain adrenal tumors, and prior inflammation. Calcification may also be seen in some cases of adrenal insufficiency caused by infections such as tuberculosis, but it is not a typical feature of autoimmune Addison disease. In many patients, small adrenal calcifications identified incidentally on imaging represent the residual finding of a prior process that resolved long ago, often without ever having been recognized clinically.
The clinical significance of adrenal hemorrhage and calcification depends heavily on the extent of adrenal involvement and whether adrenal function is affected. Because the adrenal glands have a large functional reserve, unilateral hemorrhage or partial bilateral hemorrhage often does not produce adrenal insufficiency. Extensive bilateral hemorrhage, however, can destroy enough functioning tissue to cause acute adrenal insufficiency, which can be life-threatening. Isolated adrenal calcification—particularly when small, stable, and asymptomatic—typically does not affect adrenal function.
Symptoms vary widely. Many patients with small hemorrhages or calcifications have no symptoms, and the finding is discovered incidentally on imaging done for other reasons. Symptomatic acute hemorrhage may cause upper abdominal, flank, or back pain, nausea, vomiting, fever, and low blood pressure. Bilateral hemorrhage with acute adrenal insufficiency (adrenal crisis) can produce severe fatigue, weakness, dizziness, confusion, low blood pressure, low blood sugar, low sodium, high potassium, and shock, and is a medical emergency. Symptoms of Waterhouse-Friderichsen syndrome typically overlap with those of the underlying severe infection, including high fever, rapid heart rate, low blood pressure, and characteristic skin findings.
Evaluation combines clinical assessment, blood tests, and imaging. Blood tests may include complete blood count, comprehensive metabolic panel (particularly sodium, potassium, and glucose), morning cortisol, ACTH, coagulation studies, blood cultures, and infection workup as appropriate. Cosyntropin (ACTH) stimulation testing may be used to assess adrenal function when adrenal insufficiency is suspected. CT of the abdomen is the primary imaging test and can show characteristic findings of adrenal hemorrhage (such as enlarged, high-density adrenal glands in acute bleeding) and calcification. MRI provides excellent characterization of hemorrhage at different ages and helps distinguish hemorrhage from other adrenal lesions. Ultrasound is often used in newborns. Follow-up imaging is important to document evolution and, in some cases, to distinguish hemorrhage from an underlying adrenal mass, since bleeding within a tumor can obscure the underlying lesion until the hemorrhage resolves.
Important to Know
Management of adrenal hemorrhage and calcification depends on the acuity of the bleeding, the extent of adrenal involvement, whether adrenal function is affected, and the underlying cause. Adrenal calcification alone—particularly when small, stable, and asymptomatic—usually requires no specific treatment beyond documentation in the medical record.
Acute adrenal hemorrhage may be a medical emergency, particularly when it is bilateral or associated with adrenal insufficiency. Initial management includes supportive care with fluids, correction of electrolyte abnormalities (particularly low sodium, high potassium, and low blood sugar), and hemodynamic support in patients with low blood pressure or shock. Empiric treatment with intravenous glucocorticoids (such as hydrocortisone) is often started when adrenal insufficiency is suspected, given that missed adrenal crisis can be rapidly fatal. Blood tests to assess adrenal function are obtained but do not delay life-saving treatment.
Identification and treatment of the underlying cause is essential. Sepsis is treated with prompt antibiotics, supportive care, and management of the underlying infection—including specific attention to meningococcal disease when present. Anticoagulation-related bleeding may require reversal of anticoagulation, correction of clotting parameters, and reevaluation of the risks and benefits of continued anticoagulation once the acute event is stabilized. Antiphospholipid syndrome and other clotting disorders are managed in collaboration with hematology, often with adjustments to anticoagulation strategies. Trauma-related hemorrhage is managed based on the overall injury pattern, with attention to the possibility of associated abdominal injuries. Bleeding within adrenal tumors—particularly when malignancy or pheochromocytoma is suspected—may require additional evaluation and, in selected cases, surgery once the acute event has stabilized.
Long-term adrenal insufficiency after significant hemorrhage requires lifelong hormone replacement with glucocorticoids and, when needed, mineralocorticoids. Patients receive detailed education about “stress dosing” during illness, injury, or surgery; medical alert identification; and emergency injection kits. Regular follow-up with endocrinology helps ensure appropriate hormone replacement and monitoring.
For patients with adrenal calcification identified incidentally on imaging, evaluation is generally focused on identifying any underlying cause that requires attention and confirming that adrenal function is normal. Blood tests to assess adrenal function may be considered depending on the extent of calcification and clinical context. In many patients, no specific treatment is needed beyond routine care and clear documentation of the finding.
For patients with a history of adrenal hemorrhage, follow-up imaging is often appropriate to confirm evolution and rule out an underlying adrenal mass. The timing and modality of follow-up are individualized based on the specific findings and clinical context. New or worsening symptoms warrant further evaluation.
Care is typically coordinated by hospitalists or intensivists (during acute events), endocrinologists, hematologists, infectious disease specialists, surgeons, interventional radiologists, and primary care clinicians. Imaging and laboratory findings are interpreted alongside the patient’s symptoms, examination, and broader clinical context rather than in isolation.
Patient education plays an important role, particularly regarding the recognition of adrenal insufficiency, adherence to hormone replacement (when needed), stress dosing during illness or surgery, and warning signs that warrant urgent evaluation.
Red flag symptoms include severe upper abdominal, flank, or back pain, lightheadedness or fainting, rapid heart rate, cool clammy skin or signs of shock, high fever with chills, severe weakness, severe vomiting, confusion, low blood pressure, low blood sugar, or signs of severe infection. These warrant immediate emergency evaluation, as they may indicate acute adrenal hemorrhage, adrenal crisis, sepsis, or other serious conditions.