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Adrenal abscess as a complication of adrenal fine-needle biopsy
BRIEFCLINICALOBSERVATIONS
Adrenal Abscessas a Complication of Adrenal Fine-Needle Biopsy L. MASMIQUEL,C. HERNANDEZ-PASCUAL, R. SIMO, J. MESA, Hospital General Vail d’Hebron, Barcelona, Spain
Incidental discovery of previously unsuspected adrenal masses has been reported in 0.6% to 1.0% of patients undergoing abdominal computed tomographic (CT) scans for other reasons [l]. Fine-needle biopsy is an important tool in the differential diagnosis of these masses. We present a patient who developed an adrenal abscess after a percutaneous fine-needle biopsy of an adrenal incidentaloma. Case Report. A 63-year-old man was referred to the endocrinology service in November 1991 to evaluate an incidentally detected right adrenal mass. The patient had been studied at the gastroenterology service because of recent-onset dysphagia. A barium swallow esophagogram disclosed irregular stricture of the lower esophagus. Results of a thoracoabdominal CT scan examination were unremarkable except for the unexpected finding of a right adrenal mass (Figure 1, top). Esophagoscopy with serial brush cytologies and mucosal biopsies established the diagnosis of chronic reflux esophagitis. Vanillylmandelic acid, free catecholamines, and cortisol levels in a 24-hour urine collection were all within normal values. Plasma levels of cortisol, testosterone, and dehydroepiandrosterone sulfate were also normal. An overnight dexamethasone suppression test showed a normal response. Histologic examination of a fine-needle aspiration biopsy specimen of the gland was suggestive of adrenal adenoma. Five days after the fine-needle biopsy procedure, the patient developed shaking chills, and his temperature increased to 39.7”C. Fever and chills persisted during the ensuing days. Results of physical examination and laboratory analyses remained unchanged except for mild neutrophilia. Radiographs were again normal, and blood and urine cultures were negative. A repeated abdominal CT scan showed a marked increase in size of the adrenal gland, which appeared as a low-density, well-encapsulated mass (Figure 1, bottom). At laparotomy, a large adrenal mass filled with pus was removed. Histologic examination of the mass showed multiple coalescent abscesses along with a complete loss of the normal adrenal architecture. Culture of pus obtained by needle aspiration grew Bacteroides thetaiotaomicron and Klebsiella After surgery and appropriate antipneumoniae. microbial therapy, the patient improved rapidly and was discharged asymptomatic 7 days later. 244
August 1993 The American Journal of Medicine
Volume
Figure 1. Top. CT scan
disclosing a 7 X 5-cm mass with images of calcification in the right adrenal region. Bottom. CT scan 10 days after the percutaneous biopsy, showing enlargement of the mass with an enhancing margin surrounding hypodense content.
Comments. Adrenal abscess is a rare entity that has been reported mainly among newborns, as a complication of adrenal hemorrhage [2]. Only two cases among adults have been reported in the literature [3,4]. Both cases presented with prolonged fever, flank pain, and leukocytosis, and the diagnosis was confirmed at laparotomy. Some features of our case deserve further comment. First, our patient developed fever and leukocytosis 5 days after fine-needle aspiration biopsy, and hence it seems likely that the procedure and the complication were directly related. Complications of percutaneous fine-needle biopsy have been reported infrequently, pneumothorax and hemorrhage being the most common [5]. Hemorrhage has been observed in 4% to 7% of patients undergoing 95
BRIEF CLINICAL
this diagnostic procedure. Frequently, hemorrhage is very mild, remains asymptomatic, and can only be identified by CT scan and a slight decrease in hematocrit. It is possible that this complication was unnoticed in our patient and favored subsequent bacterial infection. However, we cannot rule out the possibility that bacterial seeding occurred during the fine-needle biopsy procedure. Second, to our knowledge, this is the first report of adrenal abscess complicating adrenal percutaneous fine-needle aspiration biopsy. Because of the frequent use of this diagnostic technique, adrenal abscess should be considered in any patient who develops fever after an adrenal biopsy.
REFERENCES 1. Glazer GM. MR imaging of the liver, kidneys and adrenal glands. Radiology 1988; 166: 303-12. 2. Atkinson
RR. Adrenal abscess in the neocoliabscess
adrenal mass. Ann intern Med 1985; 103: 481. 4. O’Brien WM, Copeland CJ, Klappenbach RS, Lynch JH. Computed phy of adrenal abscess. J Comput Assist Tomogr 1987; 11: 550-l. 5. Bernardino accuracy, Submitted
ME, Walther
MM, Phillips VM, et a/. CT-guided
safety, and indications. September
as an
tomogra-
adrenal biopsy:
Am J Roentgen01 1985; 144 67-9.
28, 1992, and accepted
in revised form
December
2,
1992 ACKNOWLEDGMENT:
APRIL H. TEITELBAUM, M.D., Amgen Center, Thousand Oaks, California, ANNE J. BELL, Ph.D., Amgen Ltd., Cambridge, England, SHERRI L. BROWN, M.D., Amgen Center, Thousand Oaks, California
Idiosyncratic noncytotoxic drug-induced agranulocytosis, a severe selective neutropenia due to an unpredictable adverse reaction to a wide variety of drugs in hypersensitive individuals, is a serious disorder [l]. Granulocyte recovery depends upon the extent of damage to neutrophil precursors, and marrow recovery may be prolonged if granulocyte precursor aplasia is evident. Administration of r-metHuG-CSF (filgrastim, Neupogen; Amgen, Thousand Oaks, CA) as an adjunct to myelotoxic chemotherapy results in an abbreviated duration of chemotherapy-induced absolute neutrophil count (ANC) nadir as well as a decreased frequency of morbidity (i.e., febrile neutropenia) [2]. The benefit of filgrastim in patients with congenital agranulocytosis has been described, and neutrophils obtained from individuals treated with filgrastim function normally in vitro and in With the availability of filgrastim, accelerated myeloid recovery is possible, introducing the potential to mitigate often life-threatening infections in individuals with iatrogenic drug-induced neutropenia. Prior to approval by the Food and Drug Administration, 8 patients with noncytotoxic drug-induced agranulocytosis in the United States were treated with filgrastim on a compassionate-use protocol, with 14 patients in Europe treated in a similar
GO, Kodroff MB, Gay BB, Ricketts
nate. Radiology 1985; 155: 101-4. 3. Echaniz A, De Miguel J. Arnal A, Pedreira JD. Escherichia
Filgrastim (r-metHuG-CSF) Reversalof Drug-Induced Agranulocytosis
vivo [3,4].
OBSERVATIONS
We are grateful to Dr. J.I. Esteban for his comments.
manner. Protocol requisites included ANC less than 1,000/mm3 in the U.S. and less than 500/mm3 in Europe, cessation of the suspected offending drug, lack of exposure to cytotoxic drugs, and demonstration of granulocyte aplasia or hypoplasia on bone marrow biopsy. Because at least 7 days elapse from the time myelocytes are identified in the marrow until their appearance as circulating peripheral blood neutrophils, absence of marrow granulocyte precursors indicated imminent neutrophil recovery was unlikely [5]. Spontaneous neutrophil recovery may take as long as 15 to 30 days after withdrawal of the offending drug [6]. As seen in Table I, neutrophil recovery (ANC greater than 1,000/mm3) occurred within 1 to 15 days (median 4 days) after initiation of filgrastim in doses of 4 to 10 pg/kg/d. The range for ANC recovery is not surprising since seven of these individuals had developed complicated bacterial, fungal, or viral infections prior to or after identification of agranulocytosis. At least seven patients had received aggressive antibiotic and/or antifungal medication for 7 or more days before initiation of filgrastim. Two patient deaths occurred from causes unrelated to filgrastim use. Complete clinical recovery was evident in the remaining 20 patients, with clinical improvement coincident to myeloid recovery. Filgrastim was well tolerated, with mild bone pain noted by one patient and headache noted by two individuals. A patient who experienced dyspnea was subsequently diagnosed with fungal pneumonia, and also developed a skin rash temporally related to antibiotic administration. Drug eruptions that occurred in two other patients were related temporally to antibiotic administration. Although this was not a controlled clinical trial, the experience reported demonstrates the apparent
August
1993
The American
Journal
of Medicine
Volume
95
245
Adrenal Abscessas a Complication of Adrenal Fine-Needle Biopsy L. MASMIQUEL,C. HERNANDEZ-PASCUAL, R. SIMO, J. MESA, Hospital General Vail d’Hebron, Barcelona, Spain
Incidental discovery of previously unsuspected adrenal masses has been reported in 0.6% to 1.0% of patients undergoing abdominal computed tomographic (CT) scans for other reasons [l]. Fine-needle biopsy is an important tool in the differential diagnosis of these masses. We present a patient who developed an adrenal abscess after a percutaneous fine-needle biopsy of an adrenal incidentaloma. Case Report. A 63-year-old man was referred to the endocrinology service in November 1991 to evaluate an incidentally detected right adrenal mass. The patient had been studied at the gastroenterology service because of recent-onset dysphagia. A barium swallow esophagogram disclosed irregular stricture of the lower esophagus. Results of a thoracoabdominal CT scan examination were unremarkable except for the unexpected finding of a right adrenal mass (Figure 1, top). Esophagoscopy with serial brush cytologies and mucosal biopsies established the diagnosis of chronic reflux esophagitis. Vanillylmandelic acid, free catecholamines, and cortisol levels in a 24-hour urine collection were all within normal values. Plasma levels of cortisol, testosterone, and dehydroepiandrosterone sulfate were also normal. An overnight dexamethasone suppression test showed a normal response. Histologic examination of a fine-needle aspiration biopsy specimen of the gland was suggestive of adrenal adenoma. Five days after the fine-needle biopsy procedure, the patient developed shaking chills, and his temperature increased to 39.7”C. Fever and chills persisted during the ensuing days. Results of physical examination and laboratory analyses remained unchanged except for mild neutrophilia. Radiographs were again normal, and blood and urine cultures were negative. A repeated abdominal CT scan showed a marked increase in size of the adrenal gland, which appeared as a low-density, well-encapsulated mass (Figure 1, bottom). At laparotomy, a large adrenal mass filled with pus was removed. Histologic examination of the mass showed multiple coalescent abscesses along with a complete loss of the normal adrenal architecture. Culture of pus obtained by needle aspiration grew Bacteroides thetaiotaomicron and Klebsiella After surgery and appropriate antipneumoniae. microbial therapy, the patient improved rapidly and was discharged asymptomatic 7 days later. 244
August 1993 The American Journal of Medicine
Volume
Figure 1. Top. CT scan
disclosing a 7 X 5-cm mass with images of calcification in the right adrenal region. Bottom. CT scan 10 days after the percutaneous biopsy, showing enlargement of the mass with an enhancing margin surrounding hypodense content.
Comments. Adrenal abscess is a rare entity that has been reported mainly among newborns, as a complication of adrenal hemorrhage [2]. Only two cases among adults have been reported in the literature [3,4]. Both cases presented with prolonged fever, flank pain, and leukocytosis, and the diagnosis was confirmed at laparotomy. Some features of our case deserve further comment. First, our patient developed fever and leukocytosis 5 days after fine-needle aspiration biopsy, and hence it seems likely that the procedure and the complication were directly related. Complications of percutaneous fine-needle biopsy have been reported infrequently, pneumothorax and hemorrhage being the most common [5]. Hemorrhage has been observed in 4% to 7% of patients undergoing 95
BRIEF CLINICAL
this diagnostic procedure. Frequently, hemorrhage is very mild, remains asymptomatic, and can only be identified by CT scan and a slight decrease in hematocrit. It is possible that this complication was unnoticed in our patient and favored subsequent bacterial infection. However, we cannot rule out the possibility that bacterial seeding occurred during the fine-needle biopsy procedure. Second, to our knowledge, this is the first report of adrenal abscess complicating adrenal percutaneous fine-needle aspiration biopsy. Because of the frequent use of this diagnostic technique, adrenal abscess should be considered in any patient who develops fever after an adrenal biopsy.
REFERENCES 1. Glazer GM. MR imaging of the liver, kidneys and adrenal glands. Radiology 1988; 166: 303-12. 2. Atkinson
RR. Adrenal abscess in the neocoliabscess
adrenal mass. Ann intern Med 1985; 103: 481. 4. O’Brien WM, Copeland CJ, Klappenbach RS, Lynch JH. Computed phy of adrenal abscess. J Comput Assist Tomogr 1987; 11: 550-l. 5. Bernardino accuracy, Submitted
ME, Walther
MM, Phillips VM, et a/. CT-guided
safety, and indications. September
as an
tomogra-
adrenal biopsy:
Am J Roentgen01 1985; 144 67-9.
28, 1992, and accepted
in revised form
December
2,
1992 ACKNOWLEDGMENT:
APRIL H. TEITELBAUM, M.D., Amgen Center, Thousand Oaks, California, ANNE J. BELL, Ph.D., Amgen Ltd., Cambridge, England, SHERRI L. BROWN, M.D., Amgen Center, Thousand Oaks, California
Idiosyncratic noncytotoxic drug-induced agranulocytosis, a severe selective neutropenia due to an unpredictable adverse reaction to a wide variety of drugs in hypersensitive individuals, is a serious disorder [l]. Granulocyte recovery depends upon the extent of damage to neutrophil precursors, and marrow recovery may be prolonged if granulocyte precursor aplasia is evident. Administration of r-metHuG-CSF (filgrastim, Neupogen; Amgen, Thousand Oaks, CA) as an adjunct to myelotoxic chemotherapy results in an abbreviated duration of chemotherapy-induced absolute neutrophil count (ANC) nadir as well as a decreased frequency of morbidity (i.e., febrile neutropenia) [2]. The benefit of filgrastim in patients with congenital agranulocytosis has been described, and neutrophils obtained from individuals treated with filgrastim function normally in vitro and in With the availability of filgrastim, accelerated myeloid recovery is possible, introducing the potential to mitigate often life-threatening infections in individuals with iatrogenic drug-induced neutropenia. Prior to approval by the Food and Drug Administration, 8 patients with noncytotoxic drug-induced agranulocytosis in the United States were treated with filgrastim on a compassionate-use protocol, with 14 patients in Europe treated in a similar
GO, Kodroff MB, Gay BB, Ricketts
nate. Radiology 1985; 155: 101-4. 3. Echaniz A, De Miguel J. Arnal A, Pedreira JD. Escherichia
Filgrastim (r-metHuG-CSF) Reversalof Drug-Induced Agranulocytosis
vivo [3,4].
OBSERVATIONS
We are grateful to Dr. J.I. Esteban for his comments.
manner. Protocol requisites included ANC less than 1,000/mm3 in the U.S. and less than 500/mm3 in Europe, cessation of the suspected offending drug, lack of exposure to cytotoxic drugs, and demonstration of granulocyte aplasia or hypoplasia on bone marrow biopsy. Because at least 7 days elapse from the time myelocytes are identified in the marrow until their appearance as circulating peripheral blood neutrophils, absence of marrow granulocyte precursors indicated imminent neutrophil recovery was unlikely [5]. Spontaneous neutrophil recovery may take as long as 15 to 30 days after withdrawal of the offending drug [6]. As seen in Table I, neutrophil recovery (ANC greater than 1,000/mm3) occurred within 1 to 15 days (median 4 days) after initiation of filgrastim in doses of 4 to 10 pg/kg/d. The range for ANC recovery is not surprising since seven of these individuals had developed complicated bacterial, fungal, or viral infections prior to or after identification of agranulocytosis. At least seven patients had received aggressive antibiotic and/or antifungal medication for 7 or more days before initiation of filgrastim. Two patient deaths occurred from causes unrelated to filgrastim use. Complete clinical recovery was evident in the remaining 20 patients, with clinical improvement coincident to myeloid recovery. Filgrastim was well tolerated, with mild bone pain noted by one patient and headache noted by two individuals. A patient who experienced dyspnea was subsequently diagnosed with fungal pneumonia, and also developed a skin rash temporally related to antibiotic administration. Drug eruptions that occurred in two other patients were related temporally to antibiotic administration. Although this was not a controlled clinical trial, the experience reported demonstrates the apparent
August
1993
The American
Journal
of Medicine
Volume
95
245