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Unilateral adrenal hemorrhage in forty-five-year-old woman
UNILATERAL ADRENAL HEMORRHAGE FORTY-FIVE-YEAR-OLD R. FRIEDRICHS,
H. RUBBEN,
WOMAN
M.D.
J. DOHRENBUSCH, B. HEINRICHS,
IN
M.D.
M.D.
M.D.
From the Departments of Urology and Pathology, RWTH, Aachen, West Germany
ABSTRACTWe herein describe a case of adrenal hemorrhage on the right side in a forty-fiveyear-old woman. Her medical history did not show any evidence of an acute bleeding. The hematoma was removed and adrenalectomy performed. A veinectasis and a localized vasculitis are discussed as causes of bleeding.
The adrenal glands are densely vascularized organs with three arteries which branch in as many as fifty arterial subdivisions whereas the venous drainage is commonly limited to a single vessel.’ The rich blood supply of the organ, its limited venous drainage, and the fineness of the vessel walls are thought to be anatomic factors which predispose to extensive hemorrhage.2 Case Report A forty-five-year-old woman was admitted to our institution for treatment of an adrenal tumor on the right side. She was seen first by her urologist because of right flank pain. The past history was unremarkable except for short episodes of painless microhematuria. The physical examination gave normal findings. Chest xray film, electrocardiogram, laboratory data, and determination of twenty-four-hour-urinary excretion of catecholamines, vanillylmandelic acid, ketosteroids, and hydroxycorticoids were without pathologic findings. Hematologic evaluation did not reveal any evidence of a bleeding diathesis. Ultrasound showed a large right supyelogram prarenal mass. An intravenous (IVP) demonstrated prompt excretion of dye bi-
UROLOGY
i
AUGUST
1988
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VOLUME
laterally. The upper pole of the right kidney was displaced. Abdominal computerized tomography (CT) scan evaluation confirmed the presence of a solid suprarenal mass in the area of the right adrenal gland (density > 60 HU) (Fig. 1A and B). Adrenal hemorrhage was considered after CT scan evaluation. The adrenal gland was approached by an extraperitoneal way through an incisioin between the tenth and eleventh rib, which was then directed pararectal. Exploration of the right flank revealed a well-encapsulated hematoma (500 mL) above and separate from the kidney. Although an adrenal tumor could not be found macroscopitally, adrenalectomy was performed. The patient was discharged from the hospital on postoperative day 10 after an uncomplicated recovery.
XxX11, NUMBER 2
Pathology In the adherent brown fat tissue of the adrenal gland (4 x 4 x 2 cm) a cyst was found (diameter 4 cm). Microscopically tissue typical of the adrenal gland with three zones was seen. Blood was detected in the subcapsular and exterior zones, shifting the cortex to the central vein
155
FIGURE1. (A) Computerized tomography scan shows solid suprarenal mass (diameter 8 cm, density >60 HU). Density of suprarenal mass is higher than that of aorta. CT scan was performed eleven days before operation. (B) After injection of contrast medium it is shown that right kidney and suprarenal mass which does not change density, are distinctly separate structures.
FIGURE2. (A) Adrenal gland tissue with three zones. Blood is detected in subcapsular and exterior zones, shifting cortex to central vein. (B) Lipophages and lymphocytes are in a process of organization (capsule).
(Fig. 2A). Blood and hematoidin were also detected in the adherent fat tissue, surrounded by necrotic and fibrotic areas. Lipophages and lymphocytes are in a process of organization (Fig. 2B). It is concluded that the hemorrhage of the adrenal gland passed the capsule, causing a fat necrosis and forming a cyst. This process is assumed to be older than two weeks. All sections showed a middle-sized vein, therefore, a veinectasis may have caused the hemorrhage. On the other side a localized vasculitis as shown by perivascular lymphocytic infiltration must be discussed. Comment Up to 0.6 per cent of autopsied patients are reported to have focal or diffuse adrenal gland
156
hemorrhage.2 A review of 2,000 consecutive autopsies yielded an incidence of 1.1 per cent of bilateral adrenal hemorrhage. Newborns and patients with meningococcemia were excluded in this study Males are more frequently affected than females in a ratio of approximately 3:2. Fifty-eight per cent of patients were fifty years of age and older. Compared with adults adrenal hemorrhage occurs in children in a seven-fold incidence.2,3 Most often adrenal hemorrhage in newborns appears to follow traumatic delivery. 4,5Unilateral adrenal hemorrhage is found after administration of ACTH, anticoagulant, or antiarthritic agents.B Unilateral adrenal hemorrhage usually involves the right adrenal gland. This may be due to the more vulnerable position in front of the spinal
UROLOGY
/ AUGUST 1988
i
VOLUME
XXXII,
NUMBER 2
column and its direct venous drainage into the inferior vena cava.4.e Bilateral hemorrhage is most frequent in women with a difficult pregnancy or delivery or in postoperative patients: 8 of 12 patients with postoperative adrenal hemorrhage and bilateral adrenal hemorrhage.’ The major clinical manifestations depend on whether one or both glands are involved, whether the function of the adrenals is partially or completely destroyed, and whether the hemorrhage is free or contained within the adrenal gland or within the retroperitoneum .‘J’ In only 7 of 34 patients were the abdominal symptoms and signs clearly attributable to adrenal hemorrhage. The most common clinical manifestations in these 7 patients were profound prostation, fever, mental aberrations, emesis, and weakness with severe, constant, localized, upper abdominal pain. l CT scanning is becoming the preferred method for imaging the adrenal gland and its disease states.s~s~loWith the use of CT scan the number of incidental adrenal masses also increases9 Adrenal gland masses may be only classified according to the endocrinologic function. Apart from adrenal hemorrhage nonfunctioning tumors include tumors of the adrenal cortex (adenoma, carcinoma), the adrenal medulla (ganglioneuroma, ganglioneuroblastoma), hamartomas and metastatic lesions.e Interestingly, our patient was not suspected clinically of having adrenal hemorrhage, and the diagnosis of adrenal bleeding was suggested after CT scan evaluation as described in 2 patients.e,e The cause of spontaneous adrenal hemorrhage is not understood. It is associated with administration of ACTH, hemorrhagic disorders, tumoral involvement of the adrenal glands, particularly pheochromocytoma, sepsis, burns, pregnancy, postoperative state, anticoagulant or antiarthritic therapy, trauma or chronic venous digestion, and during adrenal arteriogram.2J1J2 Concomitant diseases in patients with bilateral adrenal hemorrhage are acute myocardial infarction, congestive heart failure, atherosclerotic or hypertensive vascular disease, localized infection, or pituitary infarc-
UROLOGY
/
AUGUST 1988
tion2 A veinectasis or a localized vasculitis as causes of adrenal hemorrhage has not yet been discussed. l3 Though adrenal hemorrhage is rare, it always should be included in the differential diagnosis of an adrenal mass, especially in patients treated with anticoagulant or antiarthritic agents. Spontaneous adrenal hemorrhage should be considered in patients whose condition deteriorates rapidly after operation and in pregnancy.’ Early detection and appropriate therapy can be lifesaving. The possibility of subsequent adrenal insufficiency needs to be considered if adrenal bilateral hemorrhage is diagnosed.0,9
/ VOLUME XXXII, NUMBER 2
Department of Urology RWTH Aachen Paulwelsstr. D-5100 Aachen, West Germany (DR. FRIEDRICHS) References 1. Clark OH, Hall AD, and Schambelan M: Clinical manifestations of adrenal hemorrhage, Am J Surg 128: 219 (1974). 2. Xarli VP, et al: Adrenal hemorrhage in the adult, Medicine 57: 211 (1978). 3. Bottery A, and Ore11 SR: Adrenal hemorrhage and necrosis in the adult. A clinicopathological study of 23 cases, Acta Med Stand 175: 409 (1964). 4. Lebowitz JM, and Belman AB: Simultaneous idiopathic adrenal hemorrhage and renal vein thrombosis in the newborn, J Urol 129: 574 (1983). 5. Khuri FJ, et al: Adrenal hemorrhage in neonates: report of 5 cases and review of the literature, ibid 124: 684 (1980). 6. Kraus SE, Siroky MB, and Krane RJ: Unilateral adrenal hemorrhage after chronic nonsteroidal anti-inflammatory drug use, Urology 22: 627 (1983). 7. ClarKOH: Postoperative adrenal hemorrhage, Ann Surg 182: 124 (1975). 8. Swift DL, Lingeman JE, and Baum WC: Spontaneous retroperitoneal hemorrhage: a diagnostic challenge, J Urol 123: 577 (1980). 9. Ling D, Korobkin M, Silverman PM, and Dunnick NR: CT demonstration of bilateral adrenal hemorrhage, AJR 141: 307 (1983). 10. Seddon MJ, Baranetsky N, and van Boxel PJ: Adrenal “incidentalomas;“-need for surgery, Urology 25: 1 (1985). 11. Lawson DB, et al: Massive retroperitoneal adrenal hemorrhage, Surg Gyn Obstet 129: 989 (1969). 12. Dhom G. and Stadtler F: Mornholoeische Befunde an der NNR bei primaren Aldosteronismus, VirchGws Arch [A] 345: 176 (1968). 13. Dhom G: Die Nebennierenrinde, in Doerr W, and Seifert G (Eds): Spezielle Pathologie, Berlin, Springer, 1981, Bd 14 II, pp 881-902.
157
H. RUBBEN,
WOMAN
M.D.
J. DOHRENBUSCH, B. HEINRICHS,
IN
M.D.
M.D.
M.D.
From the Departments of Urology and Pathology, RWTH, Aachen, West Germany
ABSTRACTWe herein describe a case of adrenal hemorrhage on the right side in a forty-fiveyear-old woman. Her medical history did not show any evidence of an acute bleeding. The hematoma was removed and adrenalectomy performed. A veinectasis and a localized vasculitis are discussed as causes of bleeding.
The adrenal glands are densely vascularized organs with three arteries which branch in as many as fifty arterial subdivisions whereas the venous drainage is commonly limited to a single vessel.’ The rich blood supply of the organ, its limited venous drainage, and the fineness of the vessel walls are thought to be anatomic factors which predispose to extensive hemorrhage.2 Case Report A forty-five-year-old woman was admitted to our institution for treatment of an adrenal tumor on the right side. She was seen first by her urologist because of right flank pain. The past history was unremarkable except for short episodes of painless microhematuria. The physical examination gave normal findings. Chest xray film, electrocardiogram, laboratory data, and determination of twenty-four-hour-urinary excretion of catecholamines, vanillylmandelic acid, ketosteroids, and hydroxycorticoids were without pathologic findings. Hematologic evaluation did not reveal any evidence of a bleeding diathesis. Ultrasound showed a large right supyelogram prarenal mass. An intravenous (IVP) demonstrated prompt excretion of dye bi-
UROLOGY
i
AUGUST
1988
/
VOLUME
laterally. The upper pole of the right kidney was displaced. Abdominal computerized tomography (CT) scan evaluation confirmed the presence of a solid suprarenal mass in the area of the right adrenal gland (density > 60 HU) (Fig. 1A and B). Adrenal hemorrhage was considered after CT scan evaluation. The adrenal gland was approached by an extraperitoneal way through an incisioin between the tenth and eleventh rib, which was then directed pararectal. Exploration of the right flank revealed a well-encapsulated hematoma (500 mL) above and separate from the kidney. Although an adrenal tumor could not be found macroscopitally, adrenalectomy was performed. The patient was discharged from the hospital on postoperative day 10 after an uncomplicated recovery.
XxX11, NUMBER 2
Pathology In the adherent brown fat tissue of the adrenal gland (4 x 4 x 2 cm) a cyst was found (diameter 4 cm). Microscopically tissue typical of the adrenal gland with three zones was seen. Blood was detected in the subcapsular and exterior zones, shifting the cortex to the central vein
155
FIGURE1. (A) Computerized tomography scan shows solid suprarenal mass (diameter 8 cm, density >60 HU). Density of suprarenal mass is higher than that of aorta. CT scan was performed eleven days before operation. (B) After injection of contrast medium it is shown that right kidney and suprarenal mass which does not change density, are distinctly separate structures.
FIGURE2. (A) Adrenal gland tissue with three zones. Blood is detected in subcapsular and exterior zones, shifting cortex to central vein. (B) Lipophages and lymphocytes are in a process of organization (capsule).
(Fig. 2A). Blood and hematoidin were also detected in the adherent fat tissue, surrounded by necrotic and fibrotic areas. Lipophages and lymphocytes are in a process of organization (Fig. 2B). It is concluded that the hemorrhage of the adrenal gland passed the capsule, causing a fat necrosis and forming a cyst. This process is assumed to be older than two weeks. All sections showed a middle-sized vein, therefore, a veinectasis may have caused the hemorrhage. On the other side a localized vasculitis as shown by perivascular lymphocytic infiltration must be discussed. Comment Up to 0.6 per cent of autopsied patients are reported to have focal or diffuse adrenal gland
156
hemorrhage.2 A review of 2,000 consecutive autopsies yielded an incidence of 1.1 per cent of bilateral adrenal hemorrhage. Newborns and patients with meningococcemia were excluded in this study Males are more frequently affected than females in a ratio of approximately 3:2. Fifty-eight per cent of patients were fifty years of age and older. Compared with adults adrenal hemorrhage occurs in children in a seven-fold incidence.2,3 Most often adrenal hemorrhage in newborns appears to follow traumatic delivery. 4,5Unilateral adrenal hemorrhage is found after administration of ACTH, anticoagulant, or antiarthritic agents.B Unilateral adrenal hemorrhage usually involves the right adrenal gland. This may be due to the more vulnerable position in front of the spinal
UROLOGY
/ AUGUST 1988
i
VOLUME
XXXII,
NUMBER 2
column and its direct venous drainage into the inferior vena cava.4.e Bilateral hemorrhage is most frequent in women with a difficult pregnancy or delivery or in postoperative patients: 8 of 12 patients with postoperative adrenal hemorrhage and bilateral adrenal hemorrhage.’ The major clinical manifestations depend on whether one or both glands are involved, whether the function of the adrenals is partially or completely destroyed, and whether the hemorrhage is free or contained within the adrenal gland or within the retroperitoneum .‘J’ In only 7 of 34 patients were the abdominal symptoms and signs clearly attributable to adrenal hemorrhage. The most common clinical manifestations in these 7 patients were profound prostation, fever, mental aberrations, emesis, and weakness with severe, constant, localized, upper abdominal pain. l CT scanning is becoming the preferred method for imaging the adrenal gland and its disease states.s~s~loWith the use of CT scan the number of incidental adrenal masses also increases9 Adrenal gland masses may be only classified according to the endocrinologic function. Apart from adrenal hemorrhage nonfunctioning tumors include tumors of the adrenal cortex (adenoma, carcinoma), the adrenal medulla (ganglioneuroma, ganglioneuroblastoma), hamartomas and metastatic lesions.e Interestingly, our patient was not suspected clinically of having adrenal hemorrhage, and the diagnosis of adrenal bleeding was suggested after CT scan evaluation as described in 2 patients.e,e The cause of spontaneous adrenal hemorrhage is not understood. It is associated with administration of ACTH, hemorrhagic disorders, tumoral involvement of the adrenal glands, particularly pheochromocytoma, sepsis, burns, pregnancy, postoperative state, anticoagulant or antiarthritic therapy, trauma or chronic venous digestion, and during adrenal arteriogram.2J1J2 Concomitant diseases in patients with bilateral adrenal hemorrhage are acute myocardial infarction, congestive heart failure, atherosclerotic or hypertensive vascular disease, localized infection, or pituitary infarc-
UROLOGY
/
AUGUST 1988
tion2 A veinectasis or a localized vasculitis as causes of adrenal hemorrhage has not yet been discussed. l3 Though adrenal hemorrhage is rare, it always should be included in the differential diagnosis of an adrenal mass, especially in patients treated with anticoagulant or antiarthritic agents. Spontaneous adrenal hemorrhage should be considered in patients whose condition deteriorates rapidly after operation and in pregnancy.’ Early detection and appropriate therapy can be lifesaving. The possibility of subsequent adrenal insufficiency needs to be considered if adrenal bilateral hemorrhage is diagnosed.0,9
/ VOLUME XXXII, NUMBER 2
Department of Urology RWTH Aachen Paulwelsstr. D-5100 Aachen, West Germany (DR. FRIEDRICHS) References 1. Clark OH, Hall AD, and Schambelan M: Clinical manifestations of adrenal hemorrhage, Am J Surg 128: 219 (1974). 2. Xarli VP, et al: Adrenal hemorrhage in the adult, Medicine 57: 211 (1978). 3. Bottery A, and Ore11 SR: Adrenal hemorrhage and necrosis in the adult. A clinicopathological study of 23 cases, Acta Med Stand 175: 409 (1964). 4. Lebowitz JM, and Belman AB: Simultaneous idiopathic adrenal hemorrhage and renal vein thrombosis in the newborn, J Urol 129: 574 (1983). 5. Khuri FJ, et al: Adrenal hemorrhage in neonates: report of 5 cases and review of the literature, ibid 124: 684 (1980). 6. Kraus SE, Siroky MB, and Krane RJ: Unilateral adrenal hemorrhage after chronic nonsteroidal anti-inflammatory drug use, Urology 22: 627 (1983). 7. ClarKOH: Postoperative adrenal hemorrhage, Ann Surg 182: 124 (1975). 8. Swift DL, Lingeman JE, and Baum WC: Spontaneous retroperitoneal hemorrhage: a diagnostic challenge, J Urol 123: 577 (1980). 9. Ling D, Korobkin M, Silverman PM, and Dunnick NR: CT demonstration of bilateral adrenal hemorrhage, AJR 141: 307 (1983). 10. Seddon MJ, Baranetsky N, and van Boxel PJ: Adrenal “incidentalomas;“-need for surgery, Urology 25: 1 (1985). 11. Lawson DB, et al: Massive retroperitoneal adrenal hemorrhage, Surg Gyn Obstet 129: 989 (1969). 12. Dhom G. and Stadtler F: Mornholoeische Befunde an der NNR bei primaren Aldosteronismus, VirchGws Arch [A] 345: 176 (1968). 13. Dhom G: Die Nebennierenrinde, in Doerr W, and Seifert G (Eds): Spezielle Pathologie, Berlin, Springer, 1981, Bd 14 II, pp 881-902.
157