Bilateral adrenal hemorrhage is a rare potentially life-threatening event that occurs either in traumatic or nontraumatic conditions. The diagnosis is often complicated by its nonspecific presentation and its tendency to intervene in stressful critical illnesses. Due to many disorders in platelet function, hemorrhage is a major cause of morbidity and mortality in patients affected by myeloproliferative diseases. We report here the computed tomography and magnetic resonance imaging findings of a rare case of bilateral adrenal hemorrhage in a patient with myelodysplastic syndrome, emphasizing the importance of MRI in the differential diagnosis. 1. Introduction Acute bilateral adrenal hemorrhage is an extremely rare disorder and it is difficult to diagnose because of its nonspecific presentation [1]. This condition frequently occurs in association with an extreme physical stress and may lead to acute adrenal insufficiency or death if not promptly and properly treated [2]. In adults, major causes of bilateral adrenal hemorrhage are the presence of meningococcemia or sepsis from any organism [3], underlying adrenal tumors, burns, or hypotension related to hemorrhagic diathesis, especially the one caused by uncontrolled anticoagulation [4] in patients treated with heparin, warfarin, or direct thrombin inhibitors. We report a rare case of acute bilateral adrenal hemorrhage in a patient affected by myelodysplastic syndrome. 2. Case Report A 65-year-old man affected by myelodysplastic syndrome, but not already treated, was admitted to the emergency room with suspected pancreatitis. He complained of dyspnea, nausea, vomit, and acute epigastric pain with radiation to the back. There was no history of trauma or anticoagulant therapy and he denied fever, hematuria, and urinary symptoms and blood pressure was 110/80？mmHg. Laboratory tests revealed a platelet count of 82,000/mm3, prolonged INR (International Normalized Ratio) and aPTT (activated partial thromboplastin time), hyponatremia, hyperkalemia, and anemia, normal serum electrolytes, lipase, and amylase levels. A multislice computed tomography (MSCT) scan (Light-speed GE Medical Systems, Milwaukee, WI, USA) of the chest, abdomen, and pelvis was performed with administration of 110？mL of intravenous contrast agent (Iomeron 350, Bracco, Milan, Italy) at a speed of 4.0？mL/s. The exam revealed bilateral and symmetric enlargement of the adrenal glands which were round and with hyperdense areas on precontrast scans (each gland attenuation values were of 55 Hounsfield Units on an average), consistent with recent
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