SONOWORLD : Adrenal Hemorrhage Infant

Username

Password

172,656 Registered Members as of 03/20/2019.

JavaScript must be enabled in order for you to use Sonoworld.com in standard view. However, it seems JavaScript is either disabled or not supported by your browser. To use standard view, enable JavaScript by changing your browser options, then try again.

Abdomen » Retroperitoneum

Adrenal Hemorrhage in an Infant

« Back to Listing

Author(s) :

Ildiko Agoston-Vas

Sorin Dudea, MD, PhD

Nicolae Miu

Anca Butnaru

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:

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;
Imaging findings of Neonatal Adrenal Glands: AJR (online serial) 1998; 171 (4): article 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:

Diagnostic Ultrasound (volume one, 2 nd ed.) edited by Carol M. Rumach; Stephanie R. Wilson; J. William Charboneau; 1997.
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,).

Other contents by this AuthorOther Cases in This Category

Abdomen >> Retroperitoneum

Metastatic abdominal adenopathy
A young man presents with diffuse pain in the abdomen. He gives a history of cutaneous melanoma excised from the right groin. An abdominal ultrasound was performed.

Adrenal metastasis
A 60 year old man presents with hemoptysis and pleural effusion on chest X-ray.

Adrenal adenoma
A 36 year old woman with a history of end stage renal disease secondary to IgA nephropathy presents with vague abdominal pain. At the time of presentation she was on hemodialysis.

Adrenal tumor - neuroblastoma
A 3 year old child presented with pain and a lump in the right side of the abdomen. An ultrasound was performed.

Neuroblastoma
A 3 year old child presented with abdominal distention of 2 months duration. An ultrasound was performed.

Adrenogenital syndrome
This is the scan of a one day old term infant with ambiguous genitalia

Adrenal myelolipoma
This 55 year old woman was found to have microscopic hematuria on a routine physical exam. Her physician referred her for a renal sonogram. She has no flank pain.

Retroperitoneal tuberculous lymphadenopathy
A young man presents with history of low grade fever, malaise and abdominal pain. An ultrasound of the abdomen was performed.

Lymphomatous involvement of the kidneys and the retroperitoneum
A 62-year-old male with a known diagnosis of lymphoma presents for abdominal evaluation. An ultrasound was performed.

Retroperitoneal lymphadenopathy from carcinoma of the uterus
This is an abdominal scan in a woman with history of uterine cancer, status post hysterectomy and radiation.

Virilizing Adrenocortical Adenoma
A two-year old female child presented with signs of virilization. Laboratory tests confirmed the presence of increased levels of testosterone, dehydroepiandrosterone (DHEAS) and 17-hydroxy ...

Abdominal Tuberculosis With Tuberculous Lymphadenitis and Psoas Abscess
21-year-old female presents to the ED complaining of left-sided flank pain since approximately 9 p.m. the previous night. She has nausea and vomiting, and complains of light-headedness when ...