We present a 64-year-old Caucasian female with 35 pack-year smoking history and no comorbidities who initially presented to an outside facility due to acute left upper quadrant abdominal pain. She was eventually diagnosed with acute left adrenal hemorrhage, transfused packed red blood cells (PRBC), and underwent embolization of the left adrenal artery. She was later discharged to follow up with her PCP. A few days later, she presented to our hospital with complaints of shortness of breath (SOB) with exertion. The patient reported a three-week history of SOB prior to presentation, which worsened following the recent hospital discharge. She was hemodynamically stable upon presentation. Physical examination was significant for generalized pallor, jaundiced mucosa, and a large hematoma surrounding the left flank. The patient's hemoglobin on presentation was 7.5 (7.2 at discharge from the previous hospital). She also had severe orthostatic hypotension. Her other labs include urea 16, creatinine 0.89, sodium 136, potassium 4, AST 90, ALT 62, ALP 69, total bilirubin 3.4, WBC 7.6, platelets 97000, and cortisol > 20. Her chest X-ray revealed a small pleural effusion on the left, which was initially thought to be a sympathetic effusion from underlying hematoma. CT Angiogram of abdomen and pelvis revealed evidence of coiling of the left adrenal gland with a 6 cm mass likely representing hemorrhage in the left adrenal gland itself. There was a hemorrhage in the adjacent pararenal space crossing the midline in the retroperitoneum in the right paracolic gutter without evidence of active bleeding. She was admitted for further workup of her progressively worsening symptoms and etiology of the adrenal hemorrhage. Despite adequate volume resuscitation with PRBC and IV fluids, the patient remained symptomatic with no significant improvement in blood count. A repeat chest X-ray was obtained which revealed worsening of the pleural effusion, hence the patient underwent thoracentesis which revealed bloody exudative effusion (>2 million RBC) but cytology did not reveal malignant cells. Due to high suspicion of ongoing malignancy, repeat imaging was obtained. CT abdomen and pelvis revealed worsening left hematoma with additional new right adrenal hemorrhage (Figures 1 and 2). CT chest revealed scattered lymphadenopathy in the left supraclavicular neck, bilateral axilla, and left hilum with questionable metastatic adenopathy, along with a small indeterminate 5 mm left upper lobe pulmonary nodule. MRI of the brain revealed multiple scattered tiny foci concerning a metastatic disease. Eventually, the patient underwent an excisional biopsy of the right axillary lymph node, with the hope of identifying the primary tumor. While awaiting pathology reports, we also ruled out tuberculosis with QuantiFERON Gold and autoimmune etiology with an extensive workup. The plan was to evaluate the extent of the disease with imaging once pathology was available, and plan cancer treatment accordingly.
Unfortunately, the patient clinically deteriorated due to the development of disseminated intravascular coagulation (DIC). Her renal function worsened due to acute tubular necrosis related to DIC, intravascular volume depletion, and hypotension. Mentation gradually deteriorated due to uremic encephalopathy, and renal replacement therapy was planned. Following vascular catheter insertion, the patient had a large pneumothorax with hemodynamic compromise and had to be transferred to the ICU. Despite the reversal of the pneumothorax, her hemodynamics did not improve with vasopressor refractory shock and the patient succumbed to death. We received the final pathology result after her demise as "Poorly differentiated adenocarcinoma, primary lung cancer."