FRI229 Bilateral Adrenal Hemorrhage Following Deep Tissue Body Massage
Authors: Antony Mc Anto , Gundlapally Sindhusha , Russell Peyton , Storm Shelby , Patel Siddarth , Verma Vipin , Kant Ravi 
Published: October 2023

Abstract
Disclosure: M. Antony: None. S. Gundlapally: None. P. Russell: None. S. Storm: None. S. Patel: None. V. Verma: None. R. Kant: None.
Introduction: Adrenal hemorrhages have been reported in patients undergoing ACTH stimulation test using bovine- source ACTH. It can also be seen in severe stressful situations such as septicemia and extensive thermal burns due to sudden and profound adrenocortical stimulation by endogenous ACTH. Idiopathic spontaneous adrenal hemorrhage and motor vehicle accident induced adrenal hemorrhage have also been rarely reported. Coagulopathy, thromboembolic disease, and postoperative state are 3 major risk factors associated with bilateral adrenal hemorrhage. We present a unique case of a patient who presented with bilateral adrenal hemorrhage following deep tissue body massage. Clinical Case: A 44-year-old male with a past medical history of recurrent pulmonary embolism (PE) and deep venous thrombosis (DVT) due to lupus anticoagulant disorder status-post inferior vena cava (IVC) filter and recent change from Coumadin to Xarelto presented to the ED with a chief complaint of right upper quadrant (RUQ) pain extending to the right flank. Patient experienced unrelenting pain after a deep-tissue massage one week prior to presentation. Patient was seen two days prior to admission for similar complaints, but was discharged after reassuring CT abdomen/pelvis, ultrasound, and labs. He returned after pain worsened, and a repeat CT showed right adrenal hemorrhage and enlargement. Patient denied all other symptoms except pain. Vitals included BP of 144/84 mmhg, RR 20/min, HR 89/min, temp of 98.1°F, and SpO2 of 99%. Physical exam was notable only for RUQ pain and right CVA tenderness. Initial labs showed normal CBC including HGB 13.6g/dL (13-17 g/dL), HCT 37.5% (38.5-52%), and PLT 181K/microL (150-450 K/microL). Glucose 120mg/dL (70-99mg/dL), Na 129mmol/L (135-146 mmol/L), K 3.3mmol/L (3.5-5.2 mmol/L), Cl 87mmol/L (98-107 mmol/L), anion gap 17mmol/L (4-15mmol/L). LFT, serum lipase and CPK were non-contributory. PT was elevated at 24.7s (10-13s) and INR was 2.1 (0.9-1.2). Anticoagulation was stopped for three to four weeks, and nonsurgical management was recommended. Potassium supplementation was given, and the patient was continued on his hypertension medications. On further investigation, origin of the hemorrhage was determined to be traumatic secondary to the massage during which the masseuse walked on the patient. The patient was discharged after three days but was readmitted after continued abdominal pain and hyponatremia. He was diagnosed with a left-sided adrenal hemorrhage on repeat CT scan twelve days after identification of the first. Medical management was successful. Conclusion: Adrenal hemorrhage is a potentially life-threatening condition often caused by trauma, severe burns, or septicemia. Anticoagulant therapy and thromboembolic disease, as seen in our patient, are also risk factors. The atypical trauma induced by the patient's massage likely initiated the hemorrhagic event.
Presentation: Friday, June 16, 2023