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Abdomen » Retroperitoneum
Adrenal Hemorrhage in an Infant
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Presentation A two week old female infant presented with fever, loss of appetite, diarrhoea, vomiting occuring for two days and not improving after symptomatic treatment. The history revealed difficult labor, but subsequent normal development of the child. On clinical examination, the findings included 38,4 degrees (C) fever and breathing moan; heart rate of 160/min., rhythmic, but with decreased intensity. The clinical diagnosis on presentation was: acute myocarditis; left pneumonia; suspicion of enterocolitis. Laboratory examinations revealed severe decrease of the blood sodium (Na = 117mEq / l) with high values of blood potassium (K = 7,36 mEq / l) which raised the problem of kidney failure or a mineralocorticoid failure.
 
 
 
Caption: Sagittal view of the right upper quadrant
Description: Thick walled mass with inhomogeneous contents
 
 
 
Caption: Enlarged view of right upper quadrant through upper pole of right kidney
Description: Hypoechoic mass with thick walls, displacing the ipsilateral kidney inferiorly with indentation of the upper pole.
 
Differential Diagnosis
  • Adrenal hemorrhage
  • Adrenal adenoma:  a benign adrenal tumor. Hyperfunctioning adenoma can cause hyperaldosteronism, Cushing syndrome. Non functional adenoma seen in 2 – 8% of population [1].
  • Adrenal cyst: same characteristics as renal cysts, but less common. Thick wall, septations, calcifications suggests pseudocyst.
  • Neuroblastoma: most common solid abdominal mass of infancy (12% of all perinatal neoplasms). It is 3rd most common malignancy in infancy (after leukemia and CNS tumors), and 2nd most common tumor in children (Wilms more common in older kids). [2].
 
Final Diagnosis Right adrenal hemorrhage
 
Discussion     - Adrenal hemorrhage is more common in neonates than in children or adults. The condition occurs most frequently between the second and seventh days of life, when the glands are large and vascular [3]. At birth the adrenal gland is up to two times as large as it will be a few months later [4].
    - Neonatal adrenal hemorrhage is identified in 1,7 per 1000 births, its cause is undetermined and occurs especially after breech delivery. It is usually associated with severe stress, including sepsis, burns, abdominal trauma, hypotension, neonatal asphyxia. It may also occur in patients with hematologic abnormalities, including thrombocytopenia and disseminated intravascular coagulation. [5].
    - The right adrenal gland is involved in 70% of cases with bilateral involvement in 5-10% of cases. The usual explanation for susceptibility of the right adrenal is the greater likelihood of compression between the liver and the spine, and because the right adrenal vein usually drains directly into the inferior vena cava (3).
    - Ultrasound is the diagnostic tool of choice because it is safe, simple and non-invasive. Follow-up studies with ultrasound provide an easy method to document the resolution of hematomas. Early in the course of adrenal hemorrhage, the adrenals are large, hyperechoic, and mass like. Ultrasound appearance depends on the state of liquefaction within the adrenal gland. Areas of hemorrhage may range from hyperechoic through isoechoic to anechoic. Follow-up studies demonstrate decrease in size of the hemorrhagic areas [3].
- Usually the hemorrhage resolves completely, but it may calcify at the periphery. Currently, supportive medical management is usually sufficient [3].
- Complications of adrenal hemorrhage include volume loss and shock in infants, adrenal pseudocysts, and adrenal calcifications. Adrenal insufficiency can be fatal, but is rarely reported [1].
 
Case References Articles:
  1. Adrenal hemorrhage: MD eMedicine Journal, January 4 2002, Volume 3, Number 1, Authored by Dawn Light, MD, MPH, Chief, Department of Radiology, Madigan Army medical center;
  2. Imaging findings of Neonatal Adrenal Glands: AJR (online serial) 1998; 171 (4): article 3
  3. The value of Ultrasound in the Diagnosis and Management of Neonatal Adrenal Hemorrhage, Chong-Hsin Chen, Department of Radiology,Tou-fen Hospital, Miaoli; Tzu-Ang Chang, Department of Pediatric, Han-Ming Hospital, Changhwa, Taiwan; Chin J Radiol 1999; F24 (3); G107-111.
Books:
  1. Diagnostic Ultrasound (volume one, 2 nd ed.) edited by Carol M. Rumach; Stephanie R. Wilson; J. William Charboneau; 1997.
  2. Textbook of paediatrics (volume 1, third edition) edited by John O. Forfar and Gavin C. Arneil; Churchill Livingstone, Edinburgh London Melbourne and New York, 1984.
 
Technical Details Ultrasound images were obtained with a MEDISON KRETZ SONOACE 8800 MT scanner, with  5 MHz and 7,5 MHz transducers.       
 
Follow Up Specific and symptomatic treatment of the respiratory infection and adrenal failure led to improvement of the general state of the child. The hematoma was followed up by ultrasound.
a)    On reexamination at 2 weeks the right adrenal area measured 5,6 / 4,4 cm. The hematoma was delineated, with thick wall and inhomogeneous fluid content. Thick, echogenic septae were seen inside the mass. Two little, hyperechoic foci  were seen in the anterior wall of the hematoma, indicating the tendency to calcification (image 3).
b)    After seven weeks, the adrenal area measured 2,2 / 2,2 cm. The hematoma appeared spheric, and showed a rim of complete calcification of the wall. It indented the upper pole of the kidney (image4).
c)    After twentytwo weeks, in the area of the right adrenal appeared a calcified nucleus measuring 9 mm. (image 5,).
 
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