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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 8  |  Issue : 3  |  Page : 170-171

Neonatal adrenal mass with jaundice


Department of Pediatric Surgery, Maulana Azad Medical College, New Delhi, India

Date of Web Publication6-Aug-2019

Correspondence Address:
Dr. Shasanka Shekhar Panda
Department of Paediatric Surgery, Maulana Azad Medical College, New Delhi - 110 002
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcn.JCN_42_18

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  Abstract 


A neonate presenting with lumbar mass, late jaundice, and pallor, investigated on, shows echogenic mass in the right suprarenal position. Contrast-enhanced computed tomography scan revealed a cystic lesion without any enhancement, suggesting adrenal hemorrhage. Neonate was managed conservatively with serial hemoglobin and bilirubin levels. We present this case in view of rare presentation with mass, pallor, and direct hyperbilirubinemia.

Keywords: Adrenal hemorrhage, jaundice, lumbar mass, neonate


How to cite this article:
Kumar P, Panda SS, Radhakrishnan A, Sarin YK. Neonatal adrenal mass with jaundice. J Clin Neonatol 2019;8:170-1

How to cite this URL:
Kumar P, Panda SS, Radhakrishnan A, Sarin YK. Neonatal adrenal mass with jaundice. J Clin Neonatol [serial online] 2019 [cited 2019 Nov 17];8:170-1. Available from: http://www.jcnonweb.com/text.asp?2019/8/3/170/264038




  Introduction Top


Adrenal hemorrhage (AH) during the neonatal period is very rare. Mostly, it is unilateral.[1] It may be associated with difficult labor, birth trauma, birth hypoxia, or large birth weight.[2] It may be asymptomatic or may present with flank mass, anemia, jaundice, or rarely as scrotal bruising or hematoma.[3] We present a neonate with adrenal hematoma who came with suprarenal cystic mass, pallor, and late jaundice and was managed successfully by conservative methods.


  Case Report Top


A 21-day-old male neonate, full term, 2.8 kg birth weight born of vaginal delivery without any history of difficult labor presented to us with a history of abdominal lump in the right side for 4 days. The lump was noticed by the mother while giving bath to the neonate. It has been static in size. There was no history of trauma, fever, umbilical sepsis, and vomiting. No antenatal scans were done. The mother also noticed yellowish discoloration of the eyes for 3 days. The neonate was on exclusive breastfeeds, and stool was of normal color. On clinical examination, the neonate had pallor and icterus, otherwise playful. The vital signs were within the normal limits. A solitary mass was palpable in the right lumbar region of size 6 cm × 5 cm, extending to the right hypochondrium and epigastric region. It was nontender and firm in consistency. Fingers could be insinuated under the right costal margin. Differential diagnosis of right AH, neuroblastoma, and extralobar bronchopleural sequestration was kept in mind.

Laboratory investigations revealed hemoglobin of 9.2 g% and total bilirubin of 6.0 mg% with direct fraction of 2.1 mg%. Other liver enzymes and routine investigations were within the normal limits. X-ray abdomen showed calcification in the mass area. Ultrasonography (USG) revealed a 6.8 cm × 6.9 cm size hypoechoic lesion with moving internal echoes in relation to the upper pole of the right kidney, with calcification in the wall. Contrast-enhanced computed tomography (CECT) scan showed a large ill-defined peripherally enhancing hypodense cystic lesion in the right suprarenal location displacing the right kidney inferiorly with nonvisualization of the right adrenal gland and mass effect suggestive of adrenal hematoma [Figure 1]. There was a decreasing trend of the size of the mass on serial clinical examination of the neonate. Hemoglobin remained static and bilirubin levels normalized.
Figure 1: Contrast-enhanced computed tomography of the abdomen showing large ill-defined peripherally enhancing hypodense cystic lesion in the right suprarenal location (a) transverse plane (b) sagittal plane

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  Discussion Top


Neonatal AH is a relatively uncommon condition. It is present in 0.2% of newborns. Ten percent has bilateral presentation.[1] It may be associated with difficult labor, birth trauma, large birth weight or neonatal course complicated by hypoxia and asphyxia, hypotension, or coagulopathy.[2] Its presentation may be asymptomatic or may present with flank abdominal mass, anemia, jaundice, or rarely as scrotal bruising or hematoma.[3] It usually occurs at birth or during the 1st day following birth.[4] In the newborn, the adrenal gland is very large and vulnerable to vascular damage.[5] Our patient had a late presentation with mass, pallor, and jaundice. The AH may have been due to partum or postpartum stress or could be idiopathic. Our patient had direct hyperbilirubinemia at presentation. This finding may be explained by compression of mass over the porta hepatis.

It has more common presentation on the right side, as in our case.[6],[7] It has a male preponderance. The explanation for the susceptibility of the right adrenal gland may be that it is more likely to be compressed between the liver and spine and the right adrenal vein usually drains directly into the inferior vena cava, so it is prone to changes in venous pressure.[7]

USG is the investigation of choice for a neonatal adrenal mass evaluation. An adrenal hematoma in initial stages appears solid with diffuse or inhomogeneous echogenicity. On liquefaction, the mass shows mixed echogenicity with a central hypoechoic area and eventually becomes completely anechoic and cyst-like. Calcification may appear as early as 1–2 weeks after hemorrhage. CECT scan is reserved for cases with doubt. Acute-to-subacute hematomas contain areas of high attenuation ranging from 50 to 90 HU.[8]

Cystic neuroblastoma (CN) as a differential diagnosis needs special mention. When we are thinking of AH, it is prudent to follow-up closely with USG, which also helps to rule out CN. CN on follow-up USG shows mixed echogenicity with solid and cystic components.[8] If Doppler study shows blood flow over mass, and if CECT shows enhancement of the mass, neuroblastoma needs to be ruled out.[7] In a study on 28 neonates with suprarenal mass, USG showed that the hematoma started to regress after 7 days to 6 months.[9] In another study of 13 neonatal AH, USG revealed a hypoechoic mass in seven newborns (54%), a mixed solid–liquid mass in five (38%), and an echogenic mass (8%) in one. Hemorrhage disappeared within 8.6 ± 4.5 (4–16) weeks.[6] Our patient had an echogenic mass on USG, and follow-up USG after 7 days showed regression.


  Conclusion Top


AH should be kept as a differential diagnosis for flank abdominal mass, unexplained jaundice, and pallor.

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 initials 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 Top

1.
Bergami G, Malena S, Di Mario M, Fariello G. Echography in the follow-up of neonatal adrenal hemorrhage. The presentation of 14 cases. Radiol Med 1990;79:474-8.  Back to cited text no. 1
    
2.
Yarci E, Arayici S, Sari FN, Canpolat FE, Uras N, Dilmen U. Adrenal hemorrhage presenting as a scrotal hematoma in the newborn: A case report. Arch Argent Pediatr 2015;113:e161-3.  Back to cited text no. 2
    
3.
Alabsi SY, Layland T. Adrenal hemorrhage in neonates: Unusual presentation. Neonatal Netw 2015;34:220-6.  Back to cited text no. 3
    
4.
Navarro OM, Daneman A. Congenital and neonatal conditions. In: Coley BD, editor. Caffey's Pediatric Diagnostic Imaging. 12th ed. Philadelphia: Elsevier Saunders; 2013. p. 1274-9.  Back to cited text no. 4
    
5.
Amoury RA, Barth GW, Hall RT, Rhodes PG, Holder TM, Ashcraft KW. Scrotal ecchymosis: Sign of intraperitoneal hemorrhage in the newborn. South Med J 1982;75:1471-5, 1478.  Back to cited text no. 5
    
6.
Mutlu M, Karagüzel G, Aslan Y, Cansu A, Okten A. Adrenal hemorrhage in newborns: A retrospective study. World J Pediatr 2011;7:355-7.  Back to cited text no. 6
    
7.
Qureshi UA, Ahmad N, Rasool A, Choh S. Neonatal adrenal hemorrhage presenting as late-onset neonatal jaundice. J Indian Assoc Pediatr Surg 2009;14:221-3.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Gali S, Anat I. Purely cystic adrenal lesion in a newborn evolving into a solid neuroblastoma. J Clin Ultrasound 2015;43:126-8.  Back to cited text no. 8
    
9.
Yao W, Li K, Xiao X, Zheng S, Chen L. Neonatal suprarenal mass: Differential diagnosis and treatment. J Cancer Res Clin Oncol 2013;139:281-6.  Back to cited text no. 9
    


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