Case Report Incidental Lipid Poor Adrenal Mass in a Patient with...
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Hindawi Publishing Corporation Case Reports in Endocrinology Volume 2013, Article ID 379852, 3 pages http://dx.doi.org/10.1155/2013/379852 Case Report Incidental Lipid Poor Adrenal Mass in a Patient with Antiphospholipid Syndrome Subramanian Kannan, 1 Ankita Satra, 2 and Amir Hamrahian 1 1 Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic Foundation, 9500 Euclid Avenue Desk F20, Cleveland, OH 44195, USA 2 Department of Internal Medicine, Cleveland Clinic Foundation, 9500 Euclid Avenue Desk F20, Cleveland, OH 44195, USA Correspondence should be addressed to Subramanian Kannan; [email protected] Received 30 November 2012; Accepted 18 January 2013 Academic Editors: C. Capella, K. Iida, and A. Sahdev Copyright © 2013 Subramanian Kannan et al. is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Adrenal incidentalomas are commonly encountered in this era of ubiquitous imaging. e attenuation of the incidentaloma mea- sured in Hounsfield units (HU) is an important step in the work up. Attenuation less than 10 HU indicates a benign lesion in more than 98% of cases, whereas attenuation greater than 30 HU is highly suspicious for adrenocortical cancer (ACC). Adrenal hematoma is rarely suspected clinically and exhibits no specific clinical symptoms or laboratory findings. ere are multiple radiological fea- tures of adrenal hemorrhage and can mimic ACC. We present a case of an adrenal mass in a patient with antiphospholipid syndrome and discuss radiological clues to differentiate adrenal hematomas from ACC and thus avoid unnecessary surgical intervention. 1. Case Report A 65-year-old male with past history of anti-phospholipid (APL) syndrome on coumadin was admitted for acute right sided pleuritic chest pain. He was recently bridged with low molecular weight heparin aſter a right knee replacement. e CT-angiogram of the chest revealed a pulmonary infarct and a 5 cm right adrenal mass. A dedicated CT of his adrenals confirmed a right adrenal mass of 5.2 × 3.1 cm with pre- contrast attenuation of 53 Hounsfield units (HU) (Figure 1) with evidence of fat stranding, a sign of blood infiltrating fat containing retroperitoneal soſt tissue, surrounding it. e leſt adrenal gland was thickened. A review of the patient’s imaging studies was notable for normal adrenal glands on a CT scan two years ago. Lab work-up revealed a cortisol level of 4.4 mcg/dL aſter 1 mg dexamethasone suppression test, a normal plasma ACTH 28 pg/mL (8–42), and a slightly elevat- ed plasma normetanephrine 1.2 nmol/L (<0.9). Given the clinical circumstances of APL syndrome, history of anticoag- ulation and radiological features, a close monitoring of the adrenal mass was planned. A repeat CT scan at 2 months showed a decrease in right adrenal mass and noncontrast CT attenuation value to 4.5 × 2.6 cm and 32 HU, respectively. Another CT scan done at 4 months showed 50% reduction in size (2.6 × 1.4 cm) and attenuation reduced to 21 HU (Figure 2(a)). e CT washout showed no significant enhancement or de-enhancement (Figure 2(b)). Leſt adrenal gland appeared normal. What is the diagnosis? 2. Discussion e various causes of an incidentally detected adrenal mass are listed in Table 1. Patient’s adrenal mass imaging charac- teristics are consistent with an adrenal hematoma. e 1 mg dexamethasone suppression test was repeated on outpatient basis and subclinical cushing’s syndrome was ruled out. Adrenal hematomas may present as a solid mass with high attenuation value (50–90 HU) on CT scan. In contrast to adrenal metastasis and adrenocortical carcinoma they do not enhance with contrast and therefore have a very low washout percentage [1]. Adrenal hematomas decrease in size and attenuation on follow-up imaging and the majority undergo complete resolution [2]. e appearance of an adrenal hematoma on MRI evolves predictably over time due
Transcript of Case Report Incidental Lipid Poor Adrenal Mass in a Patient with...
Hindawi Publishing CorporationCase Reports in EndocrinologyVolume 2013, Article ID 379852, 3 pageshttp://dx.doi.org/10.1155/2013/379852
Case ReportIncidental Lipid Poor Adrenal Mass in a Patient withAntiphospholipid Syndrome
Subramanian Kannan,1 Ankita Satra,2 and Amir Hamrahian1
1 Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic Foundation,9500 Euclid Avenue Desk F20, Cleveland, OH 44195, USA
2Department of Internal Medicine, Cleveland Clinic Foundation, 9500 Euclid Avenue Desk F20,Cleveland, OH 44195, USA
Correspondence should be addressed to Subramanian Kannan; [email protected]
Received 30 November 2012; Accepted 18 January 2013
Academic Editors: C. Capella, K. Iida, and A. Sahdev
Copyright © 2013 Subramanian Kannan et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.
Adrenal incidentalomas are commonly encountered in this era of ubiquitous imaging. The attenuation of the incidentaloma mea-sured in Hounsfield units (HU) is an important step in the work up. Attenuation less than 10HU indicates a benign lesion in morethan 98%of cases, whereas attenuation greater than 30HU is highly suspicious for adrenocortical cancer (ACC). Adrenal hematomais rarely suspected clinically and exhibits no specific clinical symptoms or laboratory findings. There are multiple radiological fea-tures of adrenal hemorrhage and canmimicACC.We present a case of an adrenalmass in a patient with antiphospholipid syndromeand discuss radiological clues to differentiate adrenal hematomas from ACC and thus avoid unnecessary surgical intervention.
1. Case Report
A 65-year-old male with past history of anti-phospholipid(APL) syndrome on coumadin was admitted for acute rightsided pleuritic chest pain. He was recently bridged with lowmolecular weight heparin after a right knee replacement.TheCT-angiogram of the chest revealed a pulmonary infarct anda 5 cm right adrenal mass. A dedicated CT of his adrenalsconfirmed a right adrenal mass of 5.2 × 3.1 cm with pre-contrast attenuation of 53 Hounsfield units (HU) (Figure 1)with evidence of fat stranding, a sign of blood infiltrating fatcontaining retroperitoneal soft tissue, surrounding it. Theleft adrenal gland was thickened. A review of the patient’simaging studies was notable for normal adrenal glands on aCT scan two years ago. Lab work-up revealed a cortisol levelof 4.4mcg/dL after 1mg dexamethasone suppression test, anormal plasma ACTH 28 pg/mL (8–42), and a slightly elevat-ed plasma normetanephrine 1.2 nmol/L (<0.9). Given theclinical circumstances of APL syndrome, history of anticoag-ulation and radiological features, a close monitoring of theadrenal mass was planned. A repeat CT scan at 2 monthsshowed a decrease in right adrenal mass and noncontrast
CT attenuation value to 4.5 × 2.6 cm and 32HU, respectively.Another CT scan done at 4 months showed 50% reductionin size (2.6 × 1.4 cm) and attenuation reduced to 21HU(Figure 2(a)). The CT washout showed no significantenhancement or de-enhancement (Figure 2(b)). Left adrenalgland appeared normal. What is the diagnosis?
2. Discussion
The various causes of an incidentally detected adrenal massare listed in Table 1. Patient’s adrenal mass imaging charac-teristics are consistent with an adrenal hematoma. The 1mgdexamethasone suppression test was repeated on outpatientbasis and subclinical cushing’s syndrome was ruled out.
Adrenal hematomas may present as a solid mass withhigh attenuation value (50–90HU) on CT scan. In contrastto adrenal metastasis and adrenocortical carcinoma theydo not enhance with contrast and therefore have a verylow washout percentage [1]. Adrenal hematomas decrease insize and attenuation on follow-up imaging and the majorityundergo complete resolution [2]. The appearance of anadrenal hematoma onMRI evolves predictably over time due
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Figure 1: Adrenal CT without contrast reveals right adrenal mass(thick arrow) and thickening of the left adrenal gland (arrow head).Soft tissue stranding is indicated by the thin arrows.
Table 1: Various causes of adrenal incidentalomas [3].
(a) Adrenal cortical tumorsAdenoma, nodular hyperplasia, and congenital adrenal
hyperplasiaCarcinoma
(b) Adrenal medullary tumorsPheochromocytomaGanglioneuroma/neuroblastoma
(c) Other adrenal tumorsMyelolipomaMetastasesMiscellaneous, for example, hamartoma, teratoma, lipoma,hemangiomaInfections:
Fungal: (histoplasmosis, coccidiomycosis, blastomycosis)Viral: CMVParasitic
GranulomasTuberculosisSarcoidosis
Cysts and pseudocystsHematomas
to the different components of acute, subacute, and chronichemorrhage (deoxyhemoglobin,methemoglobin, and hemo-siderin).
Acute adrenal hematomas appear isointense to hypoint-ense relative to liver on T1-weighted images and hypointenseon T2-weighted images due to deoxyhemoglobin. Suba-cute hematomas appear heterogeneous and hyperintense onT1- and T2-weighted images due to methemoglobin, whilechronic hematomas exhibit peripheral hypointensity due tothe susceptibility effects from the accumulation of hemosid-erin and development of a fibrous capsule [4]. Other patternsof adrenal hematoma include infiltrative pattern where thereis soft tissue stranding in the retroperitoneum, adreniformpattern with enlargement of the limbs of adrenal gland, and
(a) Precontrast
(b) Postcontrast
Figure 2: (a) Adrenal CT without contrast demonstrating a reduc-tion in the size and the attenuation value of right adrenalmass (thickarrow); normal left adrenal gland (arrow head); (b) postcontrastimage reveal no enhancement.
a solid mass with cystic center. The latter may also suggestthe presence of hemorrhage in an underlying mass andprompts surgical excision for conclusive diagnosis [2]. Bilat-eral adrenal hemorrhages may present with primary adrenalinsufficiency [5]. Consideration of adrenal hematoma in thedifferential diagnosis of a lipid poor adrenal mass is veryimportant since unnecessary surgical intervention can beavoided.
Follow-up imaging in 2-3 months is necessary to confirmthe diagnosis and rules out malignant adrenal masses.
References
[1] N. R. Dunnick and M. Korobkin, “Imaging of adrenal inciden-talomas: current status,”American Journal of Roentgenology, vol.179, no. 3, pp. 559–568, 2002.
[2] M. G. Sacerdote, P. T. Johnson, and E. K. Fishman, “CT ofthe adrenal gland: the many faces of adrenal hemorrhage,”Emergency Radiology, vol. 19, no. 1, pp. 53–60, 2012.
[3] D. C. Aron, “Incidentalomas. Preface,” Best Practice andResearch: Clinical Endocrinology and Metabolism, vol. 26, no. 1,pp. 1–2, 2012.
[4] J. I. Rubin, J. M. Gomori, and R. I. Grossman, “High-fieldMR imaging of extracranial hematomas,” American Journal ofRoentgenology, vol. 148, no. 4, pp. 813–817, 1987.
Case Reports in Endocrinology 3
[5] M. A. Satta, S. M. Corsello, S. Della Casa et al., “Adrenal insuf-ficiency as the first clinical manifestation of the primary anti-phospholipid antibody syndrome,” Clinical Endocrinology, vol.52, no. 1, pp. 123–126, 2000.
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