Manejo quirúrgico del quiste adrenal gigante: reporte de caso y revisión de la literatura / Surgical management of giant adrenal cyst: case report and review of the literature

OBJETIVO: Presentar un caso de quiste adrenal (QA) gigante resecado por vía mínimamente invasiva y realizar una revisión narrativa de la literatura disponible al respecto. MATERIALES Y MÉTODOS: Se presenta el caso de un paciente de sexo masculino de 54 años, con una masa retroperitoneal izquierda de crecimiento lento, asintomático, con imágenes y biopsia sugiriendo un QA complejo con sospecha de infiltración renal. Se indica una resección laparoscópica transabdominal. RESULTADOS: Se encuentra como hallazgo intraoperatorio un QA complejo hemorrágico de 9 cm de diámetro, con adherencia a la fascia de Gerota izquierda, logrando exéresis completa del QA por mínima invasión. El paciente evolucionó satisfactoriamente y fue dado de alta al segundo día posoperatorio. Es asintomático en 19 meses de seguimiento. Si bien los QA son benignos, los QA gigantes con crecimiento rápido, sintomáticos o de conversión hemorrágica, pueden ser resecados por adrenalectomía laparoscópica sin aumento de morbimortalidad. DISCUSIÓN: El abordaje laparoscópico de los QA no funcionales gigantes debe ser considerado como el manejo de elección. Es necesaria más evidencia sobre resultados en diferentes abordajes para generar recomendaciones claras. CONCLUSIÓN: Este reporte se suma a la evidencia actual en cuanto al abordaje mínimamente invasivo para QA gigantes hemorrágicos.

OBJECTIVE: Present a giant adrenal cyst (AC) case treated with minimally invasive resection and to perform a narrative literature review available. MATERIAL AND METHODS: A 54 year-old male presents with a left retroperitoneal slow growing mass, no symptoms, with a complex AC evidenced by previous images and mass biopsy, with suspected renal infiltration. A transabdominal laparoscopic resection is indicated. RESULTS: A complex hemorrhagic 9 cm diameter AC was found, with adhesions to left Gerota's fascia. Complete resection of the AC was achieved through minimally invasive approach. The patient had an uneventful clinical recovery and was discharged on the second postoperative day. On 19th month of follow-up is completely asymptomatic. Even though the AC are benign lesions, the symptomatic giant AC, with fast growing ratio, and/or hemorrhagic conversion could be resected though laparoscopic adrenalectomy, with no increased morbidity or mortality. DISCUSSION: The laparoscopic approach for giant non-functional AC should be considered as the standard of care. More evidence is required in terms of surgical approach outcomes to define clear recommendations. CONCLUSION: This report adds to the actual evidence in terms of minimally invasive approach for hemorrhagic giant AC.

DISSEMINATED FUNGAL INFECTION WITH ADRENAL INVOLVEMENT: REPORT OF TWO HIV NEGATIVE BRAZILIAN PATIENTS / Infecções fúngicas disseminadas com acometimento das supra-renais: descrição de dois pacientes brasileiros HIV-negativos

Paracoccidioidomycosis and histoplasmosis are systemic fungal infections endemic in Brazil. Disseminated clinical forms are uncommon in immunocompetent individuals. We describe two HIV-negative patients with disseminated fungal infections, paracoccidioidomycosis and histoplasmosis, who were diagnosed by biopsies of suprarenal lesions. Both were treated for a prolonged period with oral antifungal agents, and both showed favorable outcomes.

A paracoccidioidomicose e a histoplasmose são infecções fúngicas sistêmicas endêmicas no Brasil. As formas clínicas disseminadas são incomuns em pacientes imunocompetentes. Nós descrevemos dois pacientes HIV-negativos com infecções fúngicas disseminadas, paracoccidioidomicose e histoplasmose, que foram diagnosticadas por biópsias de lesões de supra-renal. Ambos foram tratados por períodos prolongados com antifúngicos orais, evoluindo com boa resposta terapêutica.

Hemorragia suprarrenal que se manifiesta como hematoma escrotal en el recién nacido: A propósito de un caso / Adrenal hemorrhage presenting as a scrotal hematoma in the newborn: A case report

La hemorragia suprarrenal neonatal es poco frecuente. Se presenta en el 0,2% de los recién nacidos. El 10% de los casos son bilaterales. Puede estar asociada a un traumatismo al nacimiento, peso alto al nacer o un curso neonatal complicado por hipoxia, asfixia, hipotensión o coagulopatía. El hematoma escrotal es una manifestación extremadamente rara de la hemorragia suprarrenal neonatal. La mayoría de los pacientes presentan tumefacción escrotal con coloración azulada. En los recién nacidos, la tumefacción escrotal, con o sin coloración azulada, puede deberse a diferentes causas. Comunicamos un caso inusual de hemorragia suprarrenal neonatal secundaria a asfixia perinatal, que se manifestó con un hematoma escrotal. El diagnóstico de hemorragia suprarrenal neonatal y hematoma escrotal fue ecográfico; el tratamiento conservador evitó la exploración quirúrgica innecesaria.

Neonatal adrenal hemorrhage is uncommon. It is present in 0,2% of newborns. Ten percent of the cases occur bilaterally. It can be associated with birth trauma, large birth weight, or neonatal course complicated by hypoxia and asphyxia, hypotension, or coagulopathy. Scrotal hematoma is an extremely rare manifestation of NAH. Most patients present scrotal swelling with bluish discolouration. Scrotal swelling with/without bluish discoloration in newborns may result from different causes. We report an unusual case of neonatal adrenal hemorrage secondary to perinatal asphyxia, associated with SH. Neonatal adrenal hemorrhage and scrotal hematoma were diagnosedby ultrasonography and treated by conservative treatment, avoiding unnecessary surgical exploration.

Hipertensión arterial maligna e hiperaldosteronismo hiperreninémico: reporte de un caso / Malignant arterial hypertension and hyperreninemic hyperaldosteronism: a case report

Se presenta el caso de una mujer de 28 años de edad, hospitalizada por hipertensión arterial severa, edema pulmonar e hipokalemia. se encontró hiperaldosteronismo hiperreninémico e imagen de una lesión nodular en la glándula suprarrenal izquierda, la cual fue extirpada mediante cirugía laparoscópica. El estudio histológico demostró hiperplasia macronodular cortical y en el postoperatorio, hubo retorno progresivo de la hipertensión e hipokalemia

Comparison of Clinico-Radiological Features between Congenital Cystic Neuroblastoma and Neonatal Adrenal Hemorrhagic Pseudocyst

OBJECTIVE: To evaluate the radiological and clinical findings of congenital cystic neuroblastomas as compared with those of the cystic presentation of neonatal adrenal hemorrhage. MATERIALS AND METHODS: We analyzed the US (n = 52), CT (n = 24), and MR (n = 4) images as well as the medical records of 28 patients harboring congenital cystic neuroblastomas (n = 16) and neonatal adrenal hemorrhagic pseudocysts (n = 14). The history of prenatal detection, location, size, presence of outer wall enhancement, internal septations, solid portion, calcification, turbidity, vascular flow on a Doppler examination, and evolution patterns were compared in two groups of cystic lesions, by Fischer's exact test. RESULTS: All (100%) neuroblastomas and three (21%) of the 14 hemorrhagic pseudocysts were detected prenatally. Both groups of cystic lesions occurred more frequently on the right side; 11 of 16 (69%) for neuroblastomas and 11 of 14 (79%) for hemorrhagic pseudocysts. The size, presence of solid portion, septum, enhancement, and turbidity did not differ significantly (p > 0.05) between the two groups of cystic lesions. However, tiny calcifications (n = 3) and vascular flow on color Doppler US (n = 3) were noted in only neuroblastomas. The cystic neuroblastomas became complex solid and cystic masses, and did not disappear for up to 90 days in the three following cases, whereas 11 of the 14 (79%) hemorrhagic pseudocysts disappeared completely and the three remaining (27%) evolved to calcifications only. CONCLUSION: Although the imaging findings of two groups of cystic lesions were similar, prenatal detection, the presence of calcification on initial images, vascularity on color Doppler US, and evolution to a more complex mass may all favor neuroblastomas.

Detección precoz de trastornos endocrinológicos / Early detection of endocrinological disorders

Se revisan los trastornos más comunes del sistema endocrino que se detectan en la consulta no especializada. Se hace énfasis en: a) Trastornos tiroideos tales como hipo o hipertiroidismo, nódulos de la tiroides y la importancia de la enfermedad de la tiroides durante el embarazo, b) la enfermedad adrenal en la hipertensión y el enfoque de la incidentaloma suprarrenal c) hiperparatiroidismo primario y la deficiencia de vitamina D d) Trastornos gonadal y la importancia de la detección precoz de la enfermedad hormonal, tanto en la disfunción ovárica y testicular

We review the most common disorders of the endocrine system that are detected in non-specialist consultation. Emphasis is placed on: a) thyroid disorders such as hypo-or hyperthyroidism, thyroid nodules and the importance of thyroid disease during pregnancy, b) adrenal disease in hypertension and the approach to the adrenal incidentaloma c) metabolic disorders such as primary hyperparathyroidism and vitamin Ddeficiency d) gonadal disorders and the importance of early detection of hormonal disease in both ovarian and testicular dysfunction

Hiperplasia endotelial papilífera de supra-renal: relato de caso / Papillary endothelial hyperplasia of adrenal: case report

Intravascular papillary endothelial hyperplasia is a benign and rare intravascular process thought to arise from an organizing thrombus. Involvement of the adrenal gland is extremely rare, with only one case reported in the literature. We report a case of this vascular lesion in the adrenal gland, treated with laparoscopic adrenalectomy.

Hemorrhagic pseudocyst of the adrenal gland causing acute abdominal pain.

Acute abdominal pain is a common clinical entity with varied etiology. Hemorrhagic pseudocysts of the adrenal gland are rare lesions that might be considered in the differential diagnosis of acute abdominal pain. Herein, we report a case of young married female presenting with acute pain abdomen and fever, who was diagnosed to have hemorrhagic pseudocyst of the adrenal gland.

Prevalence of adrenal insufficiency in critically ill patients with AIDS.

BACKGROUND: The most common endocrine disorder in patients with human immunodeficiency virus (HIV) is adrenocortical dysfunction. The prevalence of adrenal insufficiency in patients with AIDS is unclear; partly due to different tests, doses of adrenocorticotrophic hormone (ACTH), and criteria used. In addition, there is controversy regarding the assessment of adrenal insufficiency in patients with and without critical illness. OBJECTIVE: To help clarify the prevalence of adrenal insufficiency in patients with AIDS both in critical and non-critical illness, the authors compared the prevalence based on the high-dose ACTH stimulation test. MATERIAL AND METHOD: There were 26 patients with AIDS (19 males and 7 females) with a mean age of 33.6 years (range: 22-46 years). Twelve and 14 patients were in critical and non-critical illness, respectively. RESULT: Overall, the prevalence of adrenal insufficiency was 19.2% (5 of 26) and 30.8% (8 of 26) when a peak stimulated cortisol level of < 18 microg/dL and < 25 microg/dL was defined, respectively. The prevalence was 8.3% and 28.6% in critically and non-critically ill patients; respectively, when a peak stimulated cortisol level of < 18 microg/dL was defined. Finally, when a peak stimulated cortisol level of < 25 microg/dL was defined, the prevalence was 16.7% and 42.9% in critically and non-critically ill patients, respectively. CONCLUSION: Adrenal insufficiency in patients with AIDS is more prevalent than those without HIV infection, no matter what criteria of cortisol response after ACTH test are defined An adrenal testing should be performed in all hospitalized patients with AIDS, both in critical and non-critical illness.

Bilateral adrenal histoplasmosis in an immunocompetent man

Histoplasmosis is a fungal disease that is endemic in Brazil. It may present as chronic pulmonary infection or in disseminated form. Disseminated histoplasmosis frequently affects the adrenal gland; however, unilateral involvement in immunosuppressed patients is the usual presentation. We report a case of an elderly immunocompetent male with history of weight loss, fever and bilateral adrenal mass who was successfully treated with itraconazole.

Histoplasmose é uma doença fúngica endêmica no Brasil que pode se apresentar como infecção pulmonar crônica ou na forma disseminada. A histoplasmose disseminada freqüentemente acomete a glândula adrenal; entretanto, ocorre mais em pacientes imunossuprimidos e de forma unilateral. Relatamos um caso de um homem idoso imunocompetente com história de perda de peso, febre e massa adrenal bilateral que foi tratada com itraconazol, com sucesso.

Adrenalectomía laparoscópica: reporte de un caso / Laparoscopic adrenalectomy case report

Se practicó adrenalectomía laparoscópica a una paciente femenina de 49 años de edad, con diagnóstico de tumor suprarrenal derecho con hiperaldosteronismo primario. El abordaje que se utilizó fue el laparoscópico transabdominal con cuatro puertos de trabajo. La paciente egresó en buenas condiciones, con mejoría de sus comorbilidades, sin complicaciones...

Bilateral afrenal nodules due to histoplasmosis in an elderly

We report a case history of an 84-year-old elderly male patient that presented with a clinical picture suggestive of adrenal failure and bilateral adrenal nodules detected by abdominal computed tomography. A fine needle-guided biopsy was inconclusive for achieving a final diagnosis. The patient died due to septic shock and the autopsy disclosed histoplasmosis with extensive bilateral necrosis of the adrenal glands. Although the adrenal involvement in chronic disseminated histoplasmosis has been described, there have been few reports of the infection being associated with adrenal insufficiency.

Adrenalectomía laparoscópica: lecciones aprendidas en 110 procedimientos consecutivos / Lapararoscopic adrenalectomy: lessons learned from 110 consecutive procedures

Objetivo: Se presenta una serie personal de 110 adrenalectomías laparoscópicas efectuadas en forma consecutiva, destacando las indicaciones, técnica quirúrgica, complicaciones y resultados. Material y Método: Entre Junio de 1993 y Junio del 2003, se realizaron 110 adrenalectomías laparoscópicas en 102 pacientes, 62 mujeres y 40 hombres con una edad promedio de 47,2 años (8-78 años). Las indicaciones más frecuentes fueron: incidentaloma 23,6 por ciento, cáncer metastásico 22,7 por ciento, hiperaldosteronismo 17,3 por ciento,feocromocitoma 15,5 por ciento, síndrome de Cushing 7,3 por ciento, quiste adrenal 6,4 por ciento, mielolipoma 3,6 por ciento y teratoma 1,8 por ciento. Resultados: El tiempo operatorio promedio fue 94.2 minutos (25-240 minutos), el sangrado intraoperatorio fue de 116,9 mL (0-2500 mL), la conversión a cirugía abierta fue necesaria en 1 paciente (0,9 por ciento) debido a sangrado. La estadía hospitalaria fue de 2,5 días (1-10 días). Se registró complicación en 3 pacientes (2,7 por ciento) y hubo una muerte (0,9 por ciento) durante la cirugía. El tamaño promedio fue de 4,2 cm (1,5- 14 cm) y los diagnósticos anatomopatológicos más frecuentes fueron: adenoma 27,3 por ciento, hiperplasia nodular 18,2 por ciento, cáncer metastático 17,3 por ciento y feocromocitoma 14,5 por ciento. Conclusiones: La adrenalectomía laparoscópica evolucionó durante la década pasada hasta establecerse como la técnica de elección para la cirugía adrenal. Basado tanto en la experiencia personal como en los artículos aparecidos en la literatura, este abordaje reporta resultados quirúrgicos comparables a cirugía abierta, pero con claras ventajas para la cirugía laparoscópica en lo que se refiere a complicaciones, estadía hospitalaria, período de convalecencia y resultado cosmético.

Bilateral adrenal abscess in a neonate.

A 23-day-old male baby with a history of perinatal hypoxia presented with refusal of feeds and abdominal distension. The child had a right-sided cystic upper abdominal mass and features of neonatal septicemia. Abdominal ultrasound (US) and contrast-enhanced CT scan showed bilateral adrenal abscesses. Laparotomy with drainage of the abscesses successfully treated the condition. The literature on the subject is reviewed.

Pseudoquiste suprarrenal hemorrágico: Descripción de un caso y revision de la literatura / Hemorrhagic Adrenal Pseudocyst: Case Report and a Review of the Literature

Los quistes de suprarrenal son raros y aún más los pseudoquistes hemorrágicos, los que generalmente son entidades no sospechadas y que pueden presentarse con datos sugestivos de abdomen agudo. Algunos de estos pueden llegar a desarrollar ruptura con la consiguiente hemorragia retroperitoneal e incluso la muerte. Presentamos el caso de una paciente con un pseudoquiste suprarrenal hemorrágico, con un cuadro clínico sugestivo de apenaicitis.

Adrenal cysts are rare entities, and hemorrhagic pseudocysts are even less frequent. Generally, they are unsuspected during first patient evaluation and can suggest acute abdomen. We present the case of a hemorrhagic pseudocyst with sudden on set of abdominal pain and features compatible with acute appendicitis.