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| Ahead of print
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| High-resolution ultrasonography of adrenal myelolipoma |
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Ravikanth Reddy
Department of Radiology, St. John's Hospital, Bengaluru, Karnataka, India
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| Date of Submission | 07-Aug-2021 |
| Date of Decision | 23-Sep-2021 |
| Date of Acceptance | 24-Sep-2021 |
| Date of Web Publication | 26-Oct-2021 |
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| Description | |  |
A 45-year-old female from a rural background with no significant family history presented to the department of general surgery with complaints of dull right-sided flank pain for 4 weeks. She gave us a history of recent onset uncontrolled hypertension with blood pressure at 160/90 mm Hg. She was referred for high-resolution ultrasonography of the lower abdomen which revealed a well-circumscribed heterogeneously hyperechoic lesion measuring 4.4 cm × 3.8 cm in the right suprarenal location [Figure 1]a. Ultrasonography was performed using a 3.5 MHz sector or phased array probe using the best approach for viewing the right adrenal gland which was to scan from the right flank region through the intercostal space. Color Doppler demonstrated no significant vascularity. The diagnosis based on imaging findings was adrenal myelolipoma [Figure 1]b. Differential diagnosis considered based on ultrasonography findings were adrenal myelolipoma, pheochromocytoma, and exophytic renal angiomyolipoma. Serum norepinephrine levels were elevated at 988 pg/mL. Contrast-enhanced computed tomography scan of the abdomen was done which confirmed a mass lesion involving the right adrenal gland with soft tissue and fat density (−97 HU) contents. Following which the patient underwent complete surgical resection of the right suprarenal gland. Histopathology of the resected specimen demonstrated mature adipose tissue with myeloid elements and varying amounts of hemorrhage consistent with bleed within an adrenal myelolipoma. | Figure 1: (a) Longitudinal high-resolution ultrasonography image demonstrating a well-circumscribed heteroechoic lesion in the right suprarenal location (arrows) consistent with adrenal myelolipoma. (b) Color Doppler ultrasonography demonstrating no significant vascularity within the adrenal lesion
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| Discussion | | |
Adrenal myelolipomas comprise 6%–16% of incidentalomas occurring in the suprarenal gland, the commonest being adrenal adenomas. Adrenal myelolipoma is composed predominantly of mature adipose tissue admixed with the myeloid component.[1] Myelolipoma may occur in the retroperitoneum around the kidney and presacral space or in the liver; however, the adrenal gland is the most common site. They are usually hormonally inactive and asymptomatic until they reach large sizes. Giant tumors of the adrenal gland like in the index case described may rarely lead to Addisonian crisis secondary to intralesional hemorrhage.[2] Although benign in nature, diagnostic difficulties may arise while imaging adrenal myelolipoma. Literature review suggests the coexistence of adrenal myelolipomas with specific endocrinological conditions such as Congenital Adrenal Hyperplasia, Cushing's syndrome, and Addison's disease.[3] Imaging appearances vary based on individual tumor components with areas of hemorrhage appearing hypoechoic on ultrasonography. Complete surgical resection of the adrenal lesion is indicated when there is excessive hormone production as in our case with elevated norepinephrine levels.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Adapa S, Naramala S, Gayam V, Gavini F, Dhingra H, Hazard FK, et al. Adrenal incidentaloma: Challenges in diagnosing adrenal myelolipoma. J Investig Med High Impact Case Rep 2019;7:2324709619870311.  |
| 2. | Decmann Á, Perge P, Tóth M, Igaz P. Adrenal myelolipoma: A comprehensive review. Endocrine 2018;59:7-15. |
| 3. | Al-Bahri S, Tariq A, Lowentritt B, Nasrallah DV. Giant bilateral adrenal myelolipoma with congenital adrenal hyperplasia. Case Rep Surg 2014;2014:728198. |
Correspondence Address:
Ravikanth Reddy,
Department of Radiology, St. John's Hospital, Bengaluru - 560 034, Karnataka
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/am.am_94_21
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