Very rare giant adrenal myelolipoma: a tumor mimic

Adrenal myelolipoma is a very rare benign neoplasm usually unilateral, and nonsecreting, occurring in the adrenal gland which consist of fatty tissues and hematopoietic elements. Some cases of this type may cause symptoms like chronic abdominal pain however usually these tumors are small and asymptomatic. Surgery is the modality of treatment where there are severe symptoms with life threatening progression with size of tumor reaching more than 6 cm. Here we report an unusual case of a 59-year-old male with history of chronic abdominal pain from a growing right-sided large adrenal mass. With all possible hematological, histo-pathological as well as imaging investigations warranted a high suspicion for tumor mass, hence decided for surgically excision, which was both diagnostic as well as curative. The histopathological study of the excised mass confirmed the initial diagnosis of adrenal myelolipoma. Surgery is the diagnostic and curative modality of treatment for adrenal myelolipoma after all possible investigations to reach for a clinical diagnosis as well for proper planning for surgery. By this we can prevent complications like spontaneous rupture and hemorrhage of the mass, and subsequent cardiovascular shock. Management varies from individual to individual. Open radical adrenalectomy is the standard treatment for giant myelolipomas (size >10 cm), while the minimally invasive approach has been used in only few cases of small sized tumors. Although it is a benign tumor, surgery plays main role for symptomatic cases and high suspicion of malignancy.

Conservative management of an iliopsoas hematoma causing walking difficulty in an elderly patient on anticoagulation therapy: a case report

Spontaneous iliopsoas hematoma is a rare complication in patients suffering from bleeding disorders like hemophilia, Von Willebrand’s disease or those taking blood thinners like aspirin and clopidogrel or anticoagulant medications like warfarin for atrial fibrillation or post-thrombotic status. It can present as severe pain, muscle dysfunction, difficult walking or neurological dysfunction due to compression on femoral nerve or lumbar plexus. A high index of suspicion with early blood and radiological investigations like contrast enhanced computed tomography (CECT) or magnetic resonance imaging (MRI) of the part is immensely helpful in diagnosis and prompt management of such patients. A low hemoglobin or hematocrit level and a high INR is supportive while CECT or MRI of the abdomen and pelvis is confirmatory. Management in a hemodynamically and neurologically stable patient include immediate withdrawl of the anticoagulant, bed rest, infusion of I.V. fluids, vitamin K, fresh frozen plasma and packed red cell transfusion, which ensures complete recovery in most of the cases. However angio-embolization to control ongoing arterial bleeding is lifesaving when feasible or emergent open decompression and bleeding control surgery can save the life or prevent permanent neurological damage to the limb. Decompression of the hematoma by ultrasound or computed tomography guided catheter drainage is helpful alternative in few selected cases. We report an elderly patient on warfarin, who suddenly developed difficulty in walking within hours of a strained defecation, diagnosed to suffer from left iliopsoas hematoma and responded to conservative management with complete resolution of symptoms by 3 weeks.