Presentation
No significant past medical history. Casualty presentation for right renal colic. An incidental right adrenal mass, 4.8 cm in size, was detected on a routine non-enhanced KUB CT scan.
Patient Data
A round or oval, medial limb, right adrenal mass lesion, measuring 4.7 x 4.5 x 3.8 cm (CC x AP x Transverse diameter), with minimal surrounding stranding of the periadrenal fat, demonstrating a high pre-contrast density (52 HU) with no significant enhancement at post-contrast study phases, suggested an adrenal hemorrhage.
Both kidneys are normal in site, size, and orientation. No focal or diffuse parenchymal lesion is detected. No calculi, hydronephrosis, or perinephric abnormality is seen.
Right renal middle pole, small cyst measures about 1.1x 1.0 cm.
Both ureters are normal in course and caliber with no calculi, filling defect, hydroureter, or periureteric fat stranding seen.
The urinary bladder is normal in outline and enhancement.
Normal appearance of the liver, GB, CBD, pancreas, spleen, left adrenal gland, and visualized bowel loops.
Small omental fat content umbilical hernia with a defect distance of 1.5 cm.
No free fluid/air or significant lymphadenopathy is detected.
Bilaterally the lung bases are clear.
Apart from mild lumbar spondylodegenerative changes noted, the visualized bones show no evidence of destructive lesions.
IMPRESSION:
CT findings are highly suggested of spontaneous right adrenal hemorrhage, for clinical correlation and follow-up.
A round or oval, medial limb, right adrenal mass lesion (a yellow arrow) measuring about 4.8 cm in diameter with minimal surrounding periadrenal fat stranding, demonstrating a high pre-contrast density ( 51.8 HU ) with no significant enhancement at post-contrast study phases, portal phase ( 51.3 HU) and at a delayed phase of 15 minutes (51.9 UH), suggested an adrenal hematoma.
Case Discussion
A 50-year-old man with no significant past medical history presented to the emergency department with acute right loin pain. His vital signs were stable, and laboratory investigations, including renal function tests, were within normal limits. No history of trauma or anticoagulant use was reported.
Imaging Findings:
A non-enhanced KUB (kidneys, ureters, and bladder) CT scan performed to evaluate the cause of the pain revealed a 4.8 cm mass in the right adrenal gland. The mass exhibited an attenuation value of around 50 Hounsfield units (HU), higher than typical fat-containing lesions, suggesting a more complex etiology.
A CT scan with a contrast-enhancement washout protocol was performed to further characterize the lesion. The mass did not show significant enhancement, with attenuation remaining around 50 HU before and after contrast administration. The absence of enhancement suggested that the lesion had no solid or vascular component.
Based on the imaging characteristics—specifically the size, high attenuation, and lack of enhancement—the provisional radiological diagnosis was of a spontaneous adrenal hemorrhage.
Differential Diagnosis:
adrenal adenoma: Typically shows lower attenuation values on non-enhanced CT and rapid contrast washout.
adrenal myelolipoma: Characterized by macroscopic fat, showing low attenuation values.
adrenal carcinoma or metastasis: These lesions generally show contrast enhancement and irregular margins.
pheochromocytoma: This usually presents with higher attenuation on non-enhanced CT and intense enhancement with contrast.
Management and Follow-Up
Given the diagnosis of a spontaneous adrenal hemorrhage and the patient’s stable condition, conservative management was chosen.
Spontaneous adrenal hemorrhage, though rare, should be considered in patients presenting with acute abdominal or loin pain and a corresponding adrenal mass with high attenuation on non-enhanced CT.
Accurate imaging interpretation and appropriate conservative management are crucial in ensuring a favorable outcome. Regular follow-up is essential to monitor the resolution of the hematoma and to exclude any underlying adrenal pathology.
Case courtesy of Dr Elsayed Awad and Dr Safwat Almoghazi, MD.
Unable to process the form. Check for errors and try again.