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Niranjan G, Prasad P, Gupta N, Agrawal V, Mishra A, Jain N, Kapoor V. Characteristics of Bilateral Adrenal Lesions: Experience from an Indian Tertiary Care Centre. Indian J Endocrinol Metab 2024; 28:273-278. [PMID: 39086566 PMCID: PMC11288507 DOI: 10.4103/ijem.ijem_232_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 01/15/2024] [Accepted: 01/20/2024] [Indexed: 08/02/2024] Open
Abstract
Introduction The aetiologies in unilateral and bilateral adrenal lesions can be different with different clinical implications and management guidelines, the latter having aetiologies like hyperplasia, infections, infiltrative lesions and neoplasia. Bilateral tumours are more likely to have hereditary/syndromic associations. There is limited data on the clinical and pathological profile of bilateral adrenal lesions. Methods This was a retrospective study where patients with bilateral adrenal lesions were selected from a total of 266 patients with adrenal lesions who presented to our institute between January 2016 and August 2022. The demographic, laboratory and imaging data were retrieved from the Hospital Information System and patient case files. Results The study included 51 patients; the mean age at presentation was 51.15 years (range 14 to 82 years). Forty-eight patients (94.1%) were symptomatic at presentation with an average duration of symptoms being 10.68 months (range 10 days to 1 year). The most common presentation was adrenal insufficiency in 18 cases (38%), followed by fever in 17 cases (36%). The commonest aetiology, as revealed on histopathology, was histoplasmosis (n = 22, 43%), followed by pheochromocytoma (n = 11, 21.5%), metastases (n = 6, 11.7%), adrenal hyperplasia (n = 5, 9.8%), adrenocortical adenoma (n = 1, 1.9%), lymphoma (n = 3, 5.8%), neuroblastoma (n = 1, 1.9%), myelolipoma (n = 1, 1.9%) and tuberculosis (n = 1, 1.9%). Histoplasmosis and metastatic lesions were commonly seen in older people, and pheochromocytoma was associated with young age. 6/11 patients with a diagnosis of bilateral pheochromocytoma were associated with family history, genetic mutation and extra-adrenal involvement. Conclusion The approach to bilateral adrenal lesions differs from that of unilateral lesions due to differences in aetiologies and the more significant role of genetics in some bilateral tumours. The age at presentation, presenting symptoms, lesion size and biochemical features help delineate varied underlying aetiologies.
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Affiliation(s)
- Gauri Niranjan
- Department of Pathology, SGPGIMS, Lucknow, Uttar Pradesh, India
| | - Pallavi Prasad
- Department of Pathology, SGPGIMS, Lucknow, Uttar Pradesh, India
| | - Neelima Gupta
- Department of Pathology, SGPGIMS, Lucknow, Uttar Pradesh, India
| | - Vinita Agrawal
- Department of Pathology, SGPGIMS, Lucknow, Uttar Pradesh, India
| | - Anjali Mishra
- Department of Endocrine Surgery, SGPGIMS, Lucknow, Uttar Pradesh, India
| | - Neeraj Jain
- Department of Radiodiagnosis, SGPGIMS, Lucknow, Uttar Pradesh, India
| | - Vishwas Kapoor
- Department of Biostatistics and Health Informatics, SGPGIMS, Lucknow, Uttar Pradesh, India
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Carsote M, Gheorghe AM, Nistor C, Trandafir AI, Sima OC, Cucu AP, Ciuche A, Petrova E, Ghemigian A. Landscape of Adrenal Tumours in Patients with Congenital Adrenal Hyperplasia. Biomedicines 2023; 11:3081. [PMID: 38002081 PMCID: PMC10669095 DOI: 10.3390/biomedicines11113081] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/01/2023] [Accepted: 11/15/2023] [Indexed: 11/26/2023] Open
Abstract
Our aim is to update the topic of adrenal tumours (ATs) in congenital adrenal hyperplasia (CAH) based on a multidisciplinary, clinical perspective via an endocrine approach. This narrative review is based on a PubMed search of full-length, English articles between January 2014 and July 2023. We included 52 original papers: 9 studies, 8 case series, and 35 single case reports. Firstly, we introduce a case-based analysis of 59 CAH-ATs cases with four types of enzymatic defects (CYP21A2, CYP17A1, CYP17B1, and HSD3B2). Secondarily, we analysed prevalence studies; their sample size varied from 53 to 26,000 individuals. AT prevalence among CAH was of 13.3-20%. CAH prevalence among individuals with previous imaging diagnosis of AT was of 0.3-3.6%. Overall, this 10-year, sample-based analysis represents one of the most complex studies in the area of CAH-ATs so far. These masses should be taken into consideration. They may reach impressive sizes of up to 30-40 cm, with compressive effects. Adrenalectomy was chosen based on an individual multidisciplinary decision. Many tumours are detected in subjects with a poor disease control, or they represent the first step toward CAH identification. We noted a left lateralization with a less clear pathogenic explanation. The most frequent tumour remains myelolipoma. The risk of adrenocortical carcinoma should not be overlooked. Noting the increasing prevalence of adrenal incidentalomas, CAH testing might be indicated to identify non-classical forms of CAH.
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Affiliation(s)
- Mara Carsote
- Department of Endocrinology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania;
- Clinical Endocrinology Department, C.I. Parhon National Institute of Endocrinology, 020021 Bucharest, Romania; (A.-I.T.); (O.-C.S.); (E.P.); (A.G.)
| | - Ana-Maria Gheorghe
- Clinical Endocrinology Department, C.I. Parhon National Institute of Endocrinology, 020021 Bucharest, Romania; (A.-I.T.); (O.-C.S.); (E.P.); (A.G.)
- Ph.D. Doctoral School of Carol Davila, University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Claudiu Nistor
- Department 4—Cardio-Thoracic Pathology, Thoracic Surgery II Discipline, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania;
- Thoracic Surgery Department, “Dr. Carol Davila” Central Emergency University Military Hospital, 020021 Bucharest, Romania
| | - Alexandra-Ioana Trandafir
- Clinical Endocrinology Department, C.I. Parhon National Institute of Endocrinology, 020021 Bucharest, Romania; (A.-I.T.); (O.-C.S.); (E.P.); (A.G.)
- Ph.D. Doctoral School of Carol Davila, University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Oana-Claudia Sima
- Clinical Endocrinology Department, C.I. Parhon National Institute of Endocrinology, 020021 Bucharest, Romania; (A.-I.T.); (O.-C.S.); (E.P.); (A.G.)
- Ph.D. Doctoral School of Carol Davila, University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Anca-Pati Cucu
- Ph.D. Doctoral School of Carol Davila, University of Medicine and Pharmacy, 020021 Bucharest, Romania;
- Thoracic Surgery Department, “Dr. Carol Davila” Central Emergency University Military Hospital, 020021 Bucharest, Romania
| | - Adrian Ciuche
- Department 4—Cardio-Thoracic Pathology, Thoracic Surgery II Discipline, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania;
- Thoracic Surgery Department, “Dr. Carol Davila” Central Emergency University Military Hospital, 020021 Bucharest, Romania
| | - Eugenia Petrova
- Clinical Endocrinology Department, C.I. Parhon National Institute of Endocrinology, 020021 Bucharest, Romania; (A.-I.T.); (O.-C.S.); (E.P.); (A.G.)
- Department of Endocrinology, Faculty of Midwifery and Nursing, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Adina Ghemigian
- Clinical Endocrinology Department, C.I. Parhon National Institute of Endocrinology, 020021 Bucharest, Romania; (A.-I.T.); (O.-C.S.); (E.P.); (A.G.)
- Department of Endocrinology, Faculty of Midwifery and Nursing, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
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Liu H, Tang TJ, An ZM, Yu YR. Unilateral adrenal tuberculosis whose computed tomography imaging characteristics mimic a malignant tumor: A case report. World J Clin Cases 2022; 10:5783-5788. [PMID: 35979131 PMCID: PMC9258357 DOI: 10.12998/wjcc.v10.i17.5783] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 12/18/2021] [Accepted: 04/04/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Adrenal tuberculosis usually presents with bilateral involvement. It has special characteristics in computed tomography (CT) images, such as small size, low attenuation in the center, and peripheral rim enhancement, which differ from those of primary tumors.
CASE SUMMARY A 42-year-old female presented to the hospital with low back pain. She had been diagnosed with hypertension as well as pulmonary and cerebral tuberculosis but denied having any fever, fatigue, anorexia, night sweats, cough, or weight loss. Abdominal CT revealed an irregular 6.0 cm × 4.5 cm mass with uneven density in the right adrenal gland, while the left adrenal gland was normal. No abnormalities were observed in plasma total cortisol (8 am), adrenocorticotropic hormone, aldosterone/renin ratio, blood catecholamines, or urine catecholamines. A fine-needle aspiration biopsy of the right adrenal gland provided evidence of tuberculosis. After three years of anti-tuberculosis treatments, the large mass in the right adrenal gland was reduced to a slight enlargement.
CONCLUSION This is a case of unilateral adrenal tuberculosis with CT imaging characteristics mimicking those of a malignant tumor. Extended anti-tuberculosis therapy is recommended in such cases.
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Affiliation(s)
- Hui Liu
- Department of General Practice, West China Hospital of Sichuan University, Chengdu 610041, Sichuan, China
| | - Tian-Jiao Tang
- The Center of Gerontology and Geriatrics, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Zhen-Mei An
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Ye-Rong Yu
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
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Van Bogaert C, Vierasu I, Mathey C, Theunissen A, Goldman S. Bilateral cytomegalovirus infection of the adrenal glands revealed by 18F-FDG PET/CT in a patient with T-cell lymphoma. Clin Case Rep 2022; 10:e05005. [PMID: 35127088 PMCID: PMC8795922 DOI: 10.1002/ccr3.5005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 10/04/2021] [Accepted: 10/10/2021] [Indexed: 12/26/2022] Open
Abstract
This case report demonstrates the possible subclinical adrenal and pancreatic involvement in immunocompromised patients (in particular those with lymphoma) with a CMV infection and the role of whole-body 18F-FDG PET/CT in detecting these lesions.
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Affiliation(s)
| | - Irina Vierasu
- Department of Nuclear MedicineCUB‐Hôpital ErasmeBruxellesBelgium
| | - Céline Mathey
- Department of Nuclear MedicineCUB‐Hôpital ErasmeBruxellesBelgium
| | | | - Serge Goldman
- Department of Nuclear MedicineCUB‐Hôpital ErasmeBruxellesBelgium
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Primary bilateral adrenal lymphoma masquerading as a metastatic melanoma: An unusual presentation of a rare disease. HUMAN PATHOLOGY: CASE REPORTS 2021. [DOI: 10.1016/j.ehpc.2021.200536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Histoplasmosis: An Unusual Cause of Adrenal Insufficiency. AACE Clin Case Rep 2021; 7:29-31. [PMID: 33851016 PMCID: PMC7924147 DOI: 10.1016/j.aace.2020.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective Adrenal insufficiency (AI), if not diagnosed in a timely manner, can lead to fatal outcomes. Here we describe an unusual case of AI secondary to disseminated histoplasmosis (DH) and the importance of being aware of the association of infections and AI. Methods A 56-year-old Hispanic man with untreated HIV infection presented for the evaluation of left upper jaw swelling and pain. A brain magnetic resonance imaging scan revealed a 4-cm soft-tissue mass in the left maxilla. Biopsy of the mass was consistent with histoplasmosis. He was also noted to have hyponatremia and hyperkalemia, which raised the suspicion of AI. Laboratory investigation showed a baseline cortisol level of 7 μg/dL (normal, 7-23 μg/dL) and adrenocorticotropic hormone level of 86 pg/mL (normal, 7-69 pg/mL). His 60-minute cortisol level after a 250-μg cosyntropin stimulation test was 9 μg/dL (normal, 7-23 μg/dL). Computed tomography of the chest incidentally noted bilateral adrenal enlargement. An adrenal biopsy was not pursued due to the high index of clinical suspicion of DH as the etiology of AI. Results He was diagnosed with adrenal histoplasmosis because of the evidence of AI and bilateral adrenal enlargement in the setting of DH. He was started on glucocorticoid replacement for primary AI and continues to be on glucocorticoids even after 5 years of diagnosis. DH frequently involves the adrenal gland (80%) and can present as adrenal enlargement but does not always cause primary AI. Conclusion Our case demonstrates the importance of being vigilant about infections like histoplasmosis as a potential cause of AI. Delay in treatment in such cases could result in life-threatening consequences.
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Jahan S, Mahmood T, Fariduddin M, Faisal I, Morshed M, Yadav A, Shah A, Abdullah C, Chowdhury EUR, Begum F, Hasanat MA. Clinical, biochemical and imaging characteristics of adrenal histoplasmosis in immunocompetent patients in a non-endemic area: A case series. ASIAN PAC J TROP MED 2021. [DOI: 10.4103/1995-7645.326256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Zaman S, Boharoon H, Khalid N, Marks S, Alsafi A, Flora R, Hill N, Hatfield E, Meeran K. The Vanishing Adrenal Glands: A Transient Regression of Adrenal Lymphoma After a Single Dose of 1 mg Dexamethasone. AACE Clin Case Rep 2020; 7:109-112. [PMID: 34095465 PMCID: PMC8053686 DOI: 10.1016/j.aace.2020.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Objective Dexamethasone is a known treatment for lymphoma, but the potency and rapidity of its effect have not been recognized. We present a case of bilateral adrenal lymphoma that significantly reduced in size after a single dose of dexamethasone. Methods We present the clinical course and investigations, including adrenocorticotropic hormone, cortisol, short synacthen test, computed tomography (CT), and adrenal biopsy results. Results A 52-year-old man had a fall and was incidentally found to have bilateral adrenal masses (left, 6 cm; right, 5 cm) on CT. His adrenal function tests included plasma metanephrines (normetanephrine, 830 pmol/L [normal, <1180]; metanephrine, <100 pmol/L [<510]; 3-methoxytyramine, <100 pmol/L [<180]); aldosterone, 270 pmol/L( 90-700); and random cortisol, 230 nmol/L (160-550). An overnight dexamethasone suppression test with 1 mg of dexamethasone showed cortisol of <28 nmol/L (0-50). A repeat CT scan 8 days thereafter showed adrenal masses of 4.5 and 3.5 cm on the left and right, respectively. He had a follow-up CT scan 3 months later that showed adrenal lesions measuring 8 cm (left) and 9 cm (right). He subsequently presented with fatigue and dizziness. Morning cortisol of 201 nmol/L (160-550) with adrenocorticotropic hormone of 216 ng/L (10-30) indicated primary adrenal insufficiency. Mineralocorticoid and glucocorticoid replacement therapy commenced. An adrenal biopsy showed abnormal enlarged B cells, consistent with a diagnosis of diffuse large B-cell lymphoma. Conclusion A diagnosis of lymphoma should be considered when adrenal lesions shrink following even a single low dose of dexamethasone administered as a part of a diagnostic test.
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Affiliation(s)
- Shamaila Zaman
- Imperial Centre for Endocrinology and Diabetes, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Hessa Boharoon
- Imperial Centre for Endocrinology and Diabetes, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Neelam Khalid
- Imperial Centre for Endocrinology and Diabetes, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Sasha Marks
- Haematology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Ali Alsafi
- Imaging Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Rashpal Flora
- Pathology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Neil Hill
- Imperial Centre for Endocrinology and Diabetes, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Emma Hatfield
- Imperial Centre for Endocrinology and Diabetes, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Karim Meeran
- Imperial Centre for Endocrinology and Diabetes, Imperial College Healthcare NHS Trust, London, United Kingdom
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Metastatic Small-Cell Lung Cancer Presenting as Primary Adrenal Insufficiency. Case Rep Oncol Med 2020; 2020:7018619. [PMID: 32257478 PMCID: PMC7106905 DOI: 10.1155/2020/7018619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 03/03/2020] [Indexed: 11/18/2022] Open
Abstract
A 40-year-old male smoker with HIV was admitted for cough, hypotension, and abdominal pain for 5 days. Chest radiography showed a right lower lobe consolidation. CT of the chest, abdomen, and pelvis revealed paratracheal adenopathy, a 5.8 × 4.5 cm mass invading the right bronchus intermedius, and dense bilateral adrenal masses, measuring 5.4 × 4.0 cm on the right and 4.8 × 2.0 cm on the left. Laboratory studies showed white blood cell count of 18.5 K/mm3, sodium of 131 mmol/L, creatinine of 1.6 mg/dL, and CD4 count of 567 cells/mm3. The random morning cortisol level was 7.0 μg/dL, the ACTH stimulation test yielded inappropriate response, and a random serum ACTH was elevated at 83.4 pg/mL. MRI brain revealed no pituitary adenoma confirming primary adrenal insufficiency. The adrenal CT washout study was consistent with solid mass content, concerning for metastasis. Bronchoscopy with endobronchial mass and paratracheal lymph node biopsy confirmed small-cell lung cancer (SCLC). Intravenous steroids, 100 mg hydrocortisone every 8 hours, improved his hypotension and abdominal pain. PET scan revealed metabolically active right paratracheal mass, right hilar mass, and bilateral adrenal masses. Treatment included palliative chemotherapy consisting of carboplatin/etoposide/atezolizumab and chest radiation. We present this novel case to demonstrate SCLC's ability to cause primary adrenal insufficiency, as well as evaluate clinical response to chemotherapeutics.
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yang L, Zhang M, Zhao S, Hu Y, Yao J. Correlations between MDCT features and clinicopathological findings of primary adrenal lymphoma. Eur J Radiol 2019; 113:110-115. [DOI: 10.1016/j.ejrad.2019.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 01/29/2019] [Accepted: 02/01/2019] [Indexed: 12/12/2022]
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Alshahrani MA, Bin Saeedan M, Alkhunaizan T, Aljohani IM, Azzumeea FM. Bilateral adrenal abnormalities: imaging review of different entities. Abdom Radiol (NY) 2019; 44:154-179. [PMID: 29938331 DOI: 10.1007/s00261-018-1670-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Bilateral adrenal abnormalities are not infrequently encountered during routine daily radiology practice. The differential diagnoses of bilateral adrenal abnormalities include neoplastic and non-neoplastic entities. The bilateral adrenal tumors include metastasis, lymphoma, neuroblastoma, pheochromocytoma, adenoma, and myelolipoma. Non-neoplastic bilateral adrenal masses include infectious processes and haematomas. There are different diffuse bilateral adrenal changes such as adrenal atrophy, adrenal enlargement, adrenal calcifications, and altered adrenal enhancement. In this pictorial review article, we will discuss the imaging features of these entities with emphasis on their clinical implications.
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Affiliation(s)
- Meshal Ali Alshahrani
- Department of Radiology, King Faisal Specialist Hospital and Research Center, MBC-28, P.O. Box 3354, Riyadh, 11211, Saudi Arabia
| | - Mnahi Bin Saeedan
- Department of Radiology, King Faisal Specialist Hospital and Research Center, MBC-28, P.O. Box 3354, Riyadh, 11211, Saudi Arabia.
| | - Tariq Alkhunaizan
- Department of Radiology, King Faisal Specialist Hospital and Research Center, MBC-28, P.O. Box 3354, Riyadh, 11211, Saudi Arabia
| | - Ibtisam Musallam Aljohani
- Department of Radiology, King Faisal Specialist Hospital and Research Center, MBC-28, P.O. Box 3354, Riyadh, 11211, Saudi Arabia
| | - Fahad Mohammed Azzumeea
- National Guard Health Affairs, King Abdulaziz Medical City, Medical Imaging Department, Riyadh, Saudi Arabia
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Karimi F. Primary Adrenal Lymphoma Presenting with Adrenal Failure: A Case Report and Review of the Literature. Int J Endocrinol Metab 2017; 15:e12014. [PMID: 29344029 PMCID: PMC5750783 DOI: 10.5812/ijem.12014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Accepted: 08/22/2017] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Primary adrenal lymphoma is rare, with a few cases reported in the literature. Most often it manifests as bilateral adrenal lesions and adrenal insufficiency is a common complication. CASE PRESENTATION A 53-year-old male was referred with abdominal discomfort and darkening of the skin since 1 month prior to admission. His workups detected large bilateral adrenal masses. The patient was admitted due to hypotension, and was diagnosed with adrenal insufficiency. Laboratory studies showed high erythrocyte sedimentation rate (ESR), lactate dehydrogenase (LDH), and adrenocorticotropin levels. There was no other organ involvement and computed tomography (CT)-guided percutaneous biopsy of the adrenal gland revealed B-cell type of non-Hodgkin lymphoma. Replacement therapy with glucocorticoid and mineralocorticoid was initiated with remission of symptoms. After 3 months of chemotherapy his condition improved, but the patient worsened thereafter and died 2 months later. CONCLUSIONS However, this case reminded the importance of considering primary adrenal lymphoma in the differential diagnosis of bilateral adrenal masses, especially if the patient presents with adrenal insufficiency.
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Affiliation(s)
- Fariba Karimi
- Endocrinology and Metabolism Research Center, Shiraz University, Shiraz, Iran
- Corresponding author: Fariba Karimi, Zand St, Namazee Sq, Namazee Hospital, Department of Internal Medicine, Shiraz, Iran. Tel/Fax: +98-7136474316, E-mail:
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Grover S, Selhi PK, Sood N, Sood R, Kaur H. "Polka Dot Macrophages" on cytology of bilateral adrenal masses-Nailing disseminated histoplasmosis. Diagn Cytopathol 2017; 45:943-946. [PMID: 28548709 DOI: 10.1002/dc.23758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 04/20/2017] [Accepted: 05/08/2017] [Indexed: 11/06/2022]
Abstract
Histoplasma capsulatum is a saprophytic fungus that in immunocompetent individuals causes self-limited pulmonary infection; however, in immunosuppressed patients involvement of the reticuloendothelial system, alimentary tract, urinary tract, and central nervous system is fairly common. Rarely patients present with bilateral adrenal masses which mimic tuberculosis and metastasis on radiology because of associated central necrosis. Ultrasound guided FNAC aided by special stains like Periodic Acid Schiff (PAS) and Gomori Methenamine Silver (GMS) may help in early diagnosis in such dubious cases. Polka dot macrophages were the clue to diagnosis of histoplasmosis on toluidine blue rapid staining, Hematoxylin & Eosin, and Pap stained smears. We report this case because of its rarity, diagnostic difficulty on radiology, and rapidity of diagnosis by FNA due of its characteristic cytomorphology.
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Affiliation(s)
- Sumit Grover
- Department of Pathology, Dayanand Medical College & Hospital, Ludhiana, Punjab, India
| | - Pavneet Kaur Selhi
- Department of Pathology, Dayanand Medical College & Hospital, Ludhiana, Punjab, India
| | - Neena Sood
- Department of Pathology, Dayanand Medical College & Hospital, Ludhiana, Punjab, India
| | - Ridhi Sood
- Department of Pathology, Dayanand Medical College & Hospital, Ludhiana, Punjab, India
| | - Harpreet Kaur
- Department of Pathology, Dayanand Medical College & Hospital, Ludhiana, Punjab, India
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A Case Report of Bilateral Adrenal Sarcomatoid Carcinoma. Case Rep Surg 2016; 2016:3768258. [PMID: 28097033 PMCID: PMC5206412 DOI: 10.1155/2016/3768258] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 11/24/2016] [Accepted: 12/01/2016] [Indexed: 11/17/2022] Open
Abstract
Adrenocortical carcinoma (ACC) is a rare and aggressive malignancy. Sarcomatoid adrenal carcinoma is even more aggressive type of ACC. Bilateral malignant adrenal tumors are extremely rare except for those that represent metastasis from an extra-adrenal organ. Here we report a 53-year-old woman who presented with abdominal pain and weight loss. Abdominal computed tomography revealed bilateral adrenal masses and a mass in her liver. Surgical specimens showed pleomorphic tumor cells with epithelial and spindle cell morphology and immunohistochemical staining was compatible with sarcomatoid carcinoma. Sarcomatoid adrenal carcinoma should be kept in mind during the management of bilateral adrenal masses.
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Rog CJ, Rosen DG, Gannon FH. Bilateral adrenal histoplasmosis in an immunocompetent man from Texas. Med Mycol Case Rep 2016; 14:4-7. [PMID: 27995051 PMCID: PMC5154969 DOI: 10.1016/j.mmcr.2016.11.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 11/27/2016] [Accepted: 11/28/2016] [Indexed: 12/31/2022] Open
Abstract
Disseminated histoplasmosis affecting the adrenal gland(s) of immunocompetent adults is a very rare infection. Here, we present a case of bilateral adrenal histoplasmosis in an immunocompetent, 62-year-old gentleman from Texas along with a brief review of the published literature. Given the risk of patient decompensation secondary to adrenal insufficiency and the wide availability of effective treatments, adrenal histoplasmosis must be considered even in immunocompetent adults who acquire adrenal masses.
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Affiliation(s)
- Colin J Rog
- Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030, USA
| | - Daniel G Rosen
- Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030, USA
| | - Francis H Gannon
- Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030, USA
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Kalathoorakath RR, Sharma A, Sood A, Nahar U, Gorla AKR, Mittal BR. 18F-FDG PET/CT imaging and PET-guided biopsy in evaluation and treatment decision in adrenal histoplasmosis. BJR Case Rep 2016; 2:20150451. [PMID: 30459990 PMCID: PMC6243334 DOI: 10.1259/bjrcr.20150451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 02/08/2016] [Accepted: 02/10/2016] [Indexed: 11/28/2022] Open
Abstract
Histoplasmosis is a rare opportunistic fungal infection. It is commonly seen in immunocompromised individuals from endemic areas. Adrenal glands are frequently involved in the disseminated disease. Here, we present the case of a retropositive patient with constitutional symptoms, where whole-body positron emission tomography/CT scan revealed intense 18F-fludeoxyglucose uptake in bulky adrenal glands, and subsequent positron emission tomography-guided biopsy helped in establishing the diagnosis of adrenal histoplasmosis.
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Affiliation(s)
| | - Aman Sharma
- Department of Internal Medicine, PGIMER, Chandigarh, India
| | - Ashwani Sood
- Department of Nuclear Medicine, PGIMER, Chandigarh, India
| | - Uma Nahar
- Department of Histopathology, PGIMER, Chandigarh, India
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Abstract
Ultrasonography (US) is a valuable imaging tool for evaluation of different clinical conditions in children, in general and abdominal conditions, in particular. The interest in US derives primarily from the lack of ionizing radiation exposure, low cost, portability, real-time imaging and Doppler capabilities. In addition, US application requires no preparation or sedation, making it particularly attractive in the pediatric population. Because of these advantages, US has been adopted as the primary imaging tool for evaluation of a number of pediatric abdominal conditions that would have involved the use of ionising radiation in the past, e.g., pyloric stenosis, intussusception and various renal and bladder abnormalities, to name a few. Certain limitations, however, are inherent to US including large body habitus, excessive bowel gas, postoperative state and the learning curve. In addition, pediatric US is particularly challenging as the children are frequently unable to co-operate for breath holding and many of them are crying during the scanning. In the present review, the authors discuss the various applications of US in the evaluation of pediatric abdomen.
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Lomte N, Bandgar T, Khare S, Jadhav S, Lila A, Goroshi M, Kasaliwal R, Khadilkar K, Shah NS. Bilateral adrenal masses: a single-centre experience. Endocr Connect 2016; 5:92-100. [PMID: 27037294 PMCID: PMC5002952 DOI: 10.1530/ec-16-0015] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 03/31/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND Bilateral adrenal masses may have aetiologies like hyperplasia and infiltrative lesions, besides tumours. Hyperplastic and infiltrative lesions may have coexisting hypocortisolism. Bilateral tumours are likely to have hereditary/syndromic associations. The data on clinical profile of bilateral adrenal masses are limited. AIMS To analyse clinical, biochemical and radiological features, and management outcomes in patients with bilateral adrenal masses. METHODS Retrospective analysis of 70 patients with bilateral adrenal masses presenting to a single tertiary care endocrine centre from western India (2002-2015). RESULTS The most common aetiology was pheochromocytoma (40%), followed by tuberculosis (27.1%), primary adrenal lymphoma (PAL) (10%), metastases (5.7%), non-functioning adenomas (4.3%), primary bilateral macronodular adrenal hyperplasia (4.3%), and others (8.6%). Age at presentation was less in patients with pheochromocytoma (33 years) and tuberculosis (41 years) compared with PAL (48 years) and metastases (61 years) (P<0.001). The presenting symptoms for pheochromocytoma were hyperadrenergic spells (54%) and abdominal pain (29%), whereas tuberculosis presented with adrenal insufficiency (AI) (95%). The presenting symptoms for PAL were AI (57%) and abdominal pain (43%), whereas all cases of metastasis had abdominal pain. Mean size of adrenal masses was the largest in lymphoma (5.5cm) followed by pheochromocytoma (4.8cm), metastasis (4cm) and tuberculosis (2.1cm) (P<0.001). Biochemically, most patients with pheochromocytoma (92.8%) had catecholamine excess. Hypocortisolism was common in tuberculosis (100%) and PAL (71.4%) and absent with metastases (P<0.001). CONCLUSION In evaluation of bilateral adrenal masses, age at presentation, presenting symptoms, lesion size, and biochemical features are helpful in delineating varied underlying aetiologies.
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Affiliation(s)
- Nilesh Lomte
- Department of EndocrinologySeth G S Medical College, KEM Hospital, Mumbai, Maharashtra, India
| | - Tushar Bandgar
- Department of EndocrinologySeth G S Medical College, KEM Hospital, Mumbai, Maharashtra, India
| | - Shruti Khare
- Department of EndocrinologySeth G S Medical College, KEM Hospital, Mumbai, Maharashtra, India
| | - Swati Jadhav
- Department of EndocrinologySeth G S Medical College, KEM Hospital, Mumbai, Maharashtra, India
| | - Anurag Lila
- Department of EndocrinologySeth G S Medical College, KEM Hospital, Mumbai, Maharashtra, India
| | - Manjunath Goroshi
- Department of EndocrinologySeth G S Medical College, KEM Hospital, Mumbai, Maharashtra, India
| | - Rajeev Kasaliwal
- Department of EndocrinologySeth G S Medical College, KEM Hospital, Mumbai, Maharashtra, India
| | - Kranti Khadilkar
- Department of EndocrinologySeth G S Medical College, KEM Hospital, Mumbai, Maharashtra, India
| | - Nalini S Shah
- Department of EndocrinologySeth G S Medical College, KEM Hospital, Mumbai, Maharashtra, India
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Thomas AZ, Blute ML, Seitz C, Habra MA, Karam JA. Management of the Incidental Adrenal Mass. Eur Urol Focus 2016; 1:223-230. [PMID: 28723391 DOI: 10.1016/j.euf.2015.12.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 12/09/2015] [Accepted: 12/11/2015] [Indexed: 12/14/2022]
Abstract
CONTEXT Incidentally discovered adrenal masses are becoming more common in clinical practice. OBJECTIVE To review the management of the incidental adrenal mass, including initial evaluation, surveillance, medical therapy, and surgical therapy. EVIDENCE ACQUISITION A literature search of English-language publications that included the keywords adrenal incidentaloma and incidental adrenal mass was performed through July 2015 using PubMed. Relevant original articles and guidelines on the management of the incidental adrenal mass were ultimately selected for analysis, with the consensus of all authors. EVIDENCE SYNTHESIS Data from the manuscripts included in this review were synthesized, and findings were categorized into metabolic evaluation, imaging, biopsy, surgical considerations, and follow-up recommendations. CONCLUSIONS Ideally, management of patients with adrenal incidentalomas should involve a multidisciplinary approach with experienced surgeons, radiologists, and endocrinologists to determine whether such lesions are benign or malignant and functional or nonfunctional and/or whether they require surgical resection. PATIENT SUMMARY Management of patients with adrenal incidentalomas should involve a multidisciplinary approach with surgeons, radiologists, and endocrinologists to determine whether such lesions are benign or malignant and functional or nonfunctional and/or whether they require surgical resection.
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Affiliation(s)
- Arun Z Thomas
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael L Blute
- Department of Urology, Massachusetts General Hospital, Boston, MA, USA
| | - Christian Seitz
- Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Mouhammed Amir Habra
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jose A Karam
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Abstract
Adrenal malignancies can be either primary adrenal tumors or secondary metastases, with metastases representing the most common malignant adrenal lesion. While imaging cannot always clearly differentiate between various adrenal malignancies, presence of certain imaging features, in conjunction with appropriate clinical background and hormonal profile, can suggest the appropriate diagnosis. The second part of the article on adrenal imaging describes adrenal medullary tumors, secondary adrenal lesions, bilateral adrenal lesions, adrenal incidentalomas and provides an algorithmic approach to adrenal lesions based on current imaging recommendations.
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Affiliation(s)
- Ekta Dhamija
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Ananya Panda
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Chandan J. Das
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - A. K. Gupta
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
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21
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Giant bilateral adrenal myelolipoma with congenital adrenal hyperplasia. Case Rep Surg 2014; 2014:728198. [PMID: 25140269 PMCID: PMC4124659 DOI: 10.1155/2014/728198] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 05/29/2014] [Accepted: 06/03/2014] [Indexed: 11/18/2022] Open
Abstract
Myelolipomas are rare and benign neoplasms, predominant of the adrenal glands, consisting of adipose and mature hematopoietic tissue, commonly discovered incidentally with increased use of radiologic imaging. Few cases of giant bilateral adrenal masses are reported, especially in the setting of congenital adrenal hyperplasia (CAH). We report the case of a 39-year-old male with a history of CAH secondary to 21-α hydroxylase deficiency on steroids since childhood, self-discontinued during adolescence, presenting with abdominal distension, fatigue, decreased libido, and easy bruising. Imaging revealed giant bilateral adrenal masses. He subsequently underwent bilateral adrenalectomy found to be myelolipomas measuring 30 × 25 × 20 cm on the left and weighing 4.1 kg and 25 × 20 × 13 cm on the right and weighing 2.7 kg. Adrenal myelolipomas are found to coexist with many other conditions such as Cushing's syndrome, Addison's disease, and CAH. We discuss the association with high adrenocorticotropic hormone (ACTH) states and review the studies involving ACTH as proponent leading to myelolipomas. Massive growth of these tumors, as in our case, can produce compression and hemorrhagic symptoms. We believe it is possible that self-discontinuation of steroids, in the setting of CAH, may have resulted in the growth of his adrenal masses.
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Bilateral adrenal hemorrhage in a patient with myelodysplastic syndrome: value of MRI in the differential diagnosis. Case Rep Radiol 2014; 2013:479836. [PMID: 24381776 PMCID: PMC3870123 DOI: 10.1155/2013/479836] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2013] [Accepted: 11/10/2013] [Indexed: 12/05/2022] Open
Abstract
Bilateral adrenal hemorrhage is a rare potentially life-threatening event that occurs either in traumatic or nontraumatic conditions. The diagnosis is often complicated by its nonspecific presentation and its tendency to intervene in stressful critical illnesses. Due to many disorders in platelet function, hemorrhage is a major cause of morbidity and mortality in patients affected by myeloproliferative diseases. We report here the computed tomography and magnetic resonance imaging findings of a rare case of bilateral adrenal hemorrhage in a patient with myelodysplastic syndrome, emphasizing the importance of MRI in the differential diagnosis.
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23
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Shi M, Chen X, Zhou Q, Shen F. Clinical and genetic analyses of a Chinese female with 17α-hydroxylase/17,20-lyase deficiency. Gynecol Endocrinol 2014; 30:890-3. [PMID: 25027547 DOI: 10.3109/09513590.2014.943721] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS 17α-Hydroxylase/17,20-lyase deficiency (17OHD) is a rare autosomal recessive disease caused by CYP17 gene mutations. This disease is clinically characterised by hypertension, hypokalaemia, sexual infantilism in females or pseudohermaphroditism in males, and adrenal hyperplasia. This study aims to investigate a rare case of 17OHD accompanied by both cystic ovaries and massive adrenal mass. METHODS This study performed clinical, hormonal, radiological and genetic analyses. Blood samples were collected from the patient for the genetic test. Genomic DNA was extracted from peripheral blood leukocytes, and the coding sequence abnormalities of CYP17 were assessed using polymerase chain reaction and direct sequencing analysis. RESULTS The genetic analysis of CYP17 revealed compound heterozygous mutations in the individual. One was a mis-sense mutation of c.1226 C > G, which changes codon 409 in exon 7 from proline (CCG) to arginine (CGG). Another was a mutation of p.Val311Asp,fs,330X, which was first reported in a compound heterozygote mutation of Y329fs and V311fs from a Chinese patient. CONCLUSION This study presented a rare case of 17OHD accompanied by both cystic ovaries and massive adrenal mass. This study obtained significant information on the genotype-phenotype correlation of 17OHD.
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Affiliation(s)
- Mengte Shi
- a Department of Endocrinology, The First Affiliated Hospital of Wenzhou Medical University Wenzhou, Zhejiang People's Republic of China
- b Department of Emergency, The Second Affiliated Hospital of Wenzhou Medical University Wenzhou, Zhejiang People's Republic of China
| | - Xiaojun Chen
- a Department of Endocrinology, The First Affiliated Hospital of Wenzhou Medical University Wenzhou, Zhejiang People's Republic of China
| | - Qi Zhou
- a Department of Endocrinology, The First Affiliated Hospital of Wenzhou Medical University Wenzhou, Zhejiang People's Republic of China
| | - Feixia Shen
- a Department of Endocrinology, The First Affiliated Hospital of Wenzhou Medical University Wenzhou, Zhejiang People's Republic of China
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Fang B, Cho F, Lam W. Prostate gland development and adrenal tumor in a female with congenital adrenal hyperplasia: a case report and review from radiology perspective. J Radiol Case Rep 2013; 7:21-34. [PMID: 24421935 DOI: 10.3941/jrcr.v7i12.1933] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We describe a case of a female with simple virilizing congenital adrenal hyperplasia (CAH) reared as a male diagnosed at the late age of 64. Computed Tomography (CT) demonstrated a large adrenal mass, bilateral diffuse adrenal enlargement, female pelvic organs as well as a clearly visualized prostate gland. This is to the best of our knowledge the first case of such a sizable prostate gland in a female CAH patient documented on CT. We review the literature regarding aspects where radiologists may encounter CAH and the finding of presence of a prostate gland in female CAH patients.
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Affiliation(s)
- Benjamin Fang
- Department of Radiology, Queen Mary Hospital, Hong Kong
| | - Francis Cho
- Department of Radiology, Queen Mary Hospital, Hong Kong
| | - Wendy Lam
- Department of Radiology, Queen Mary Hospital, Hong Kong
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