Acute bilateral adrenal hemorrhage due to metastatic adenocarcinoma: Clinical presentation as flank pain

Adrenal metastasis is a recognized cause of bilateral adrenal hemorrhage. This condition is uncommon but potentially life threatening and usually is not diagnosed clinically before radiologic studies are performed. We discuss the case of a woman presenting to the emergency room with severe flank pain and mild anemia. Computed tomography revealed bilateral adrenal masses with hemorrhage, compatible with probable adrenal metastasis. Subsequent diagnostic work-up revealed metastatic lesions in the spine, mediastinal adenopathy, and a duodenal mass. Biopsy of the mediastinal nodes and duodenal mass each revealed metastatic adenocarcinoma of an unknown primary tumor.