Indian Journal of Urology
CASE REPORT
Year
: 2012  |  Volume : 28  |  Issue : 4  |  Page : 453--455

Nonsurgical management of bilateral adrenal abscess in newborn with therapeutic aspiration under ultrasonographic guidance


Vivek Patre1, Hulesh Mandle1, Onkar Khandwal2,  
1 Department of Radiodiagnosis, Pt. J.N.M. Medical College and Dr. B.R.A.M Hospital, Raipur (C.G.), India
2 Department of Paediatrics, Pt. J.N.M. Medical College and Dr. B.R.A.M Hospital, Raipur (C.G.), India

Correspondence Address:
Vivek Patre
Department of Radiodiagnosis, Pt. J.N.M. Medical College and Dr. B.R.A.M Hospital, Raipur (C.G.)
India

Abstract

Neonatal adrenal abscess is a rare condition. Bilateral adrenal abscess are extremely rare. We present this case focusing on the usefulness of needle aspiration under ultrasonographic guidance. The bilateral suprarenal cystic masses are identified by ultrasonography and different sequences of magnetic resonance imaging.



How to cite this article:
Patre V, Mandle H, Khandwal O. Nonsurgical management of bilateral adrenal abscess in newborn with therapeutic aspiration under ultrasonographic guidance.Indian J Urol 2012;28:453-455


How to cite this URL:
Patre V, Mandle H, Khandwal O. Nonsurgical management of bilateral adrenal abscess in newborn with therapeutic aspiration under ultrasonographic guidance. Indian J Urol [serial online] 2012 [cited 2019 Nov 16 ];28:453-455
Available from: http://www.indianjurol.com/text.asp?2012/28/4/453/105779


Full Text

 Introduction



Adrenal abscess in the neonatal period is a rare condition. So for 34 cases had been reported in the world literature to our knowledge. [1] Bilateral adrenal abscess are extremely rare. [1],[2] Early and accurate diagnosis of the condition based on perinatal history, clinical examination, and radiographic evaluation is essential because of high rate of lethal outcome with delayed therapy and avoid unnecessary laparotomy. We present this case focusing on usefulness of percutaneous needle aspiration under ultrasonographic guidance in the management. [3]

 Case Report



A 26-days-old male neonate weighing 2.9 kg presented with a history of abdominal distention for the past 4 days. The neonate was delivered at term gestation in an institution. Clinical examination revealed an active infant having abdominal distention and palpable abdominal masses in bilateral upper quadrant. The laboratory data was unremarkable. Clotting test, renal function test, and urine examination were normal. Vanilmandelic acid, homovanilic acid, and catecholamine were normal. Ultrasonography was performed with Prosound-4000 (Aloka, Japan) ultrasound unit using 3.5 MHz curvilinear trasducer. Gray-scale sonography demonstrated cystic masses with internal echoes and debris at bilateral supra renal area measuring right 7.9 × 4.3 cm and left 4.4 × 4.6 cm, respectively [Figure 1].{Figure 1}

Color Doppler and power Doppler imaging confirmed avascular nature of the mass. Magnetic resonance imaging of the abdomen was performed with a 1.5 T unit (Sigma; GE, U.S.A.) revealed well-defined bilateral suprarenal cystic masses measuring 7.5 × 5.6 cm on the right side and 4.0 × 4.5 cm on the left side. The masses were hypointense to muscle on T-1 weighted imaging and markedly hyperintense on T-2 weighted imaging [Figure 2]a and b. A presumptive diagnosis of bilateral adrenal abscess was made.{Figure 2}

Ultrasonographic guidance aspiration was done through posterolateral approach using a 20 gauge needle [Figure 3]. Ninety milliliters of thick pus was aspirated from right suprarenal abscess and 60 ml from left side and the aspirate was sent for bacteriological study. Abdominal distention was reduced within 24 h. Serial ultrasonography showed gradual regression of the residual adrenal cavities. The infant was discharged after 10 days of antibiotic therapy. The culture of aspirated purulent fluid revealed no growth and there was no clinical evidence of adrenal insufficiency. After 3-months follow up ultrasonography revealed the complete resolution of bilateral suprarenal mass with foci of calcification.{Figure 3}

 Discussion



Two theories have been proposed for the development of neonatal adrenal abscess: first, hematogenous bacterial seeding of a normal adrenal gland and second, the seeding of a neonatal adrenal hemorrhage with subsequent abscess formation. [4],[5] In some cases, the etiology may be unclear. [6] It is likely that most adrenal abscesses begin with adrenal hemorrhage that is not infrequently associated with traumatic or difficult delivery, hypoxia, sepsis, and coagulopathy. [4],[5],[7] In most reported cases, bacterial examination of abscess material revealed E. coil, [3],[6],[8] or Staph aureus [7] but Streptococcus, Bacteriodes, Echovirus, and Herpes simplex could also be isolated. [3],[4],[9],[10] Our patient, bacteriological studies was negative.

Differential diagnosis of adrenal collection includes adrenal hemorrhage, cyst, neuroblastoma, Wilm's tumor, renal duplication with dilatation of the upper segment and hydronephrosis. [3],[4],[6] An early and accurate diagnosis of neonatal adrenal abscess is essential to avoid a potentially lethal outcome, as bilateral adrenal abscess in our case. Extension of the abscess with involvement of adjacent organs has been reported. [3],[4],[10] A case of retroperitoneal pulmonary fistula caused by a neonatal adrenal abscess has also been reported. In earlier reports, ultrasonography and intravenous pyelography (IVP) were shown to be useful for diagnosis. [3],[4] At present, CT scan and/or magnetic resonance imaging (MRI) should enable one to usually arrive at the correct preoperative diagnosis. [6]

The treatment of choice for neonatal adrenal abscess is drainage. Mondor et al., [3] described successful drainage using a pigtail catheter placed under Ultrasonography guidance. Antibiotic therapy was continued for 2 weeks. The authors stressed the need to closely follow up the patient by regularly repeated Ultrasonography until the adrenal gland is back to normal size. [3] The mainstay of treatment, especially for large lesions or where differentiation from a malignant lesion is difficult is surgical drainage with or without excision. [6],[7] In concordance with other case reports we would like to point out that percutaneous drainage under ultrasonography guidance of bilateral suprarenal abscess has good response. Ultrasonography, CT scan, and magnetic resonance imaging are essential diagnostic aids. Early diagnosis and early nonsurgical treatment may lead to a successful outcome with decreased incidence of unnecessary laparotomy.

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