Hollow Adrenal Gland Sign as an Emerging Imaging Marker of Septic Shock: A Case Report

Abstract

The hollow adrenal gland sign (HAGS) is a recently described computed tomography (CT) finding characterised by central hypoenhancement of the adrenal glands with peripheral hyperenhancement on arterial-phase contrast-enhanced imaging. It has been reported in patients with septic shock and may reflect severe haemodynamic compromise. We report the case of a 31-year-old man with no significant medical history who was admitted for surgical drainage of purulent pericarditis and subsequently developed progressive abdominal distension with clinical deterioration. On examination, he was haemodynamically unstable, with a blood pressure of 90/50 mmHg, heart rate of 140 beats/min and respiratory rate of 33 breaths/min. Laboratory investigations showed a marked inflammatory syndrome, positive infectious work-up and markedly elevated serum lactate, supporting tissue hypoperfusion and septic shock. Contrast-enhanced CT of the chest and abdomen demonstrated a moderately abundant pericardial effusion with smooth peripheral enhancement, bilateral pulmonary consolidations and bilateral HAGS. The adrenal glands were normal in size, with preserved contours and no evidence of haemorrhage or focal lesion. Additional CT findings included diffuse hepatic hypoenhancement, marked reduction in the calibre of the abdominal aorta and a large volume of intraperitoneal fluid, consistent with systemic hypoperfusion. The patient was transferred to the intensive care unit and received broad-spectrum intravenous antibiotics, fluid resuscitation, vasopressor support and close haemodynamic monitoring. Despite intensive supportive management, his condition progressed to refractory septic shock with multi-organ failure, and he died during his intensive care unit stay. This case illustrates the imaging appearance of bilateral HAGS in severe septic shock and supports its potential role as a radiological marker of shock severity.