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Objectives: The aim of this study was to assess the impact of pre-operative imaging regarding selecting cases of children's who underwent laparoscopic adrenalectomy due to adrenal masses in two tertiary medical centers., Methods: We performed a retrospective review of all laparoscopic adrenalectomy performed at two tertiary medical centers in Israel between 2017 and 2023., Results: Sixteen (n=16) patients, 10 girls and six boys, underwent laparoscopic adrenalectomy through a transperitoneal approach. The median age was 10 years (range: eight months to 17.3 years). Six masses were incidentalomas. Preoperative imaging (ultrasonography, CT, and MRI) demonstrated a mass in the right adrenal (n=9) and left adrenal (n=7), with tumor sizes ranging from 1.8 to 5.3 cm in maximum diameter. Operative results showed minimal blood loss and no conversions to laparotomy. There were no postoperative complications. Pathological diagnoses included neuroblastoma (n=8), cortical hormone-secreting tumors (n=3), pheochromocytoma (n=2), adrenal cortical adenoma (n=2), and adrenal metastatic Ewing sarcoma (n=1). Eleven masses were defined as benign and five as malignant tumors., Conclusions: Laparoscopic adrenalectomy appears to be a safe and effective technique in selected cases with adrenal masses. Among our cohort, malignant masses were more common compared to the predominantly benign adrenal masses seen in adults. Vascular encasement was a major factor in determining the feasibility of the laparoscopic approach, with preoperative imaging playing a critical role in this assessment., (© 2024 Walter de Gruyter GmbH, Berlin/Boston.)

Neonatal adrenal haemorrhage affects approximately 0.17%-0.21% of babies, although, usually, it remains asymptomatic, and therefore, the exact incidence is probably greater. The increased vascularity and relatively large size of the adrenal glands in neonates increases their vulnerability to haemorrhage during labour. There have been few cases that have presented with bowel obstruction.A term neonate was admitted with bilious vomiting, dehydration and mottled skin. He was afebrile but hypoglycaemic. Dark green aspirations were present on placement of a nasogastric tube, and emergent upper gastrointestinal contrast study demonstrated failure of contrast to pass and deviation of the duodenum. Together these features raised concern of malrotation with volvulus promoting surgical exploration. Intraoperatively, a left suprarenal mass was discovered, causing bowel obstruction. An ileostomy was created, and a biopsy was taken. Adrenal haemorrhage was diagnosed, which is an extremely rare cause of bowel obstruction. Serial ultrasound scans have been done since, showing reduction of the haemorrhage and his ileostomy has been reversed.Adrenal haemorrhage is rarely reported to cause bowel obstruction. A neonate with bilious vomiting and an abnormal contrast may represent malrotation; however, adrenal haemorrhage is an uncommon, but important, differential to consider in these scenarios., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Bilateral adrenal hemorrhage is a rare but often a fatal cause of primary adrenal insufficiency that can result in adrenal crisis if not identified and managed appropriately., Case Presentation: We present a case of a 27-year-old Caucasian female who was admitted to the hospital 17 days postpartum with pleuritic chest and flank pain, shortness of breath and nausea. Computed tomography imaging confirmed multiple thromboemboli including pulmonary emboli and noted bilateral bulky adrenal glands. She was managed for infection and pulmonary emboli; however, she complained of persistent headaches, nausea, and vomiting despite appropriate management. Radiology re-review found the computed tomography imaging was consistent with bilateral adrenal hemorrhage in hindsight. Subsequent endocrine evaluation with hypothalamic-pituitary-adrenal axis interrogation and adrenocorticotropic hormone (Synacthen) stimulation testing confirmed resultant primary adrenal insufficiency. She required urgent intravenous hydrocortisone and was subsequently discharged on oral adrenal replacement therapy and anticoagulation., Conclusions: Delay in identification and treatment of adrenal insufficiency can lead to catastrophic outcomes. This case highlights the challenge of diagnosing bilateral adrenal hemorrhage and resultant adrenal insufficiency as patients may not present with the classic risk factors, signs, symptoms, and electrolyte derangements., (© 2024. Crown.)

Neonatal adrenal hemorrhage is a rare condition with various risk factors in the pediatric population. Adrenal hemorrhage commonly affects the right side in about 70% of the cases and bilateral in about 10%. It is usually asymptomatic but can cause adrenal insufficiency and sudden death. Neonatal adrenal hemorrhage should be considered even when there are no risk factors, as it can occur spontaneously with unspecific clinical presentations. Ultrasonography can confirm diagnosis, a relatively cheap and safe modality, especially for resource-limited settings. In this case report, we present a two-day-old with progressive scrotal hematoma and inguinal ecchymosis with no risk factors. Magnetic resonance imaging confirmed right adrenal hemorrhage; however, the newborn deteriorated fast, reaching mortality within 24 hours of admission. This case illustrates the importance of recognizing the condition to allow for an evidenced approach, which may include conservative waiting, as unwarranted intervention can have negative outcomes., Competing Interests: The authors declare no competing interests., (Copyright: Jay Lodhia et al.)

Competing Interests: Competing interests: None declared.

Rationale: Adrenal infarction (AI) is a rare type of adrenal damage, which is relatively common in systemic lupus erythematosus, antiphospholipid antibody syndrome (APS) and pregnancy. The diagnosis of AI is mainly by computed tomography (CT) and magnetic resonance imaging, but is easily confused with other adrenal disease. Hence, this report details a condition of AI with systemic lupus erythematosus, APS and made a differential diagnosis from imaging., Patient Concerns: We report a case of a 55-year-old woman with pain in her fossa axillaries and inguinal regions. Then CT scan disclosed bilateral adrenal diseases, and the patient was diagnosed with systemic lupus erythematosus, APS and AI after additional autoimmune examinations., Diagnoses: The patient was diagnosed as systemic lupus erythematosus with lupus nephritis, hematological damage and oromeningitis, APS, AI and secondary blood coagulation disorders., Interventions: The patient was treated with methylprednisolone, hydroxychloroquine and low molecular heparin., Outcomes: The patient relieves and remains well 1 year after treatment., Lessons Subsections: AI can be divided hemorrhagic and non-hemorrhagic, with bilateral lesions more common. In our case, the AI was bilateral, partially involved and non-hemorrhagic, and the "cutoff sign" was first put forward in CT, which might assist the diagnosis., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Canine adrenal gland volume can be predicted based on body weight and computed tomography (CT) measurements using a validated algorithm. Use of this algorithm to detect adrenal pathology, including hyperplasia, hypoplasia and neoplasia, in clinical cases has not been described. The objective of this study was to illustrate application of the algorithm by estimating subject-specific adrenal gland volume in a historical cohort of dogs with known adrenal disease. Forty-six dogs that underwent CT and subsequent adrenalectomy were included. Clinical records and CT images from dogs that underwent adrenalectomy and histologic examination of the excised adrenal gland(s) were reviewed. Normal adrenal gland volumes for each dog were estimated using the algorithm, and compared with measured volumes of the affected glands. Linear measurement of the largest lesion diameter was also recorded. Fifty-eight adrenal glands were removed from 46 dogs, with pathology confirmed in all glands. Pathology included 28 adenomas, 13 carcinomas, 11 pheochromocytomas and 6 other benign pathologies. The volume of all removed adrenal glands was measured to be larger than the expected normal volume estimated by the algorithm, ranging from 1.1 to 212.9 times larger than estimated. Adrenal glands with malignant and benign pathology showed variable volumes with overlapping ranges recorded. Assessment of the dimensions of any focal lesion against a cut-off of 20 mm failed to discriminate malignancy. This study illustrates and supports the application of a validated volumetric algorithm for estimation of subject-specific adrenal gland volume to identify the presence of pathology and as a tool to assist clinical decision-making., (© 2024 The Authors. Australian Veterinary Journal published by John Wiley & Sons Australia, Ltd on behalf of Australian Veterinary Association.)

Background: Adrenal cysts are rare and appropriate management is unclear due to a lack of data on their natural history. Understanding adrenal cyst growth patterns would assist in clinical management., Methods: This single-institution study included all adult patients diagnosed with simple adrenal cysts between 2004 and 2021. Baseline characteristics and outcomes of those who underwent resection (ADX) or observation (OBS) were compared using the chi-squared test, student's t-test, and Wilcoxon rank-sum test. Growth curves and sensitivity analysis were plotted for all patients who had follow-up imaging., Results: We identified 77 patients with imaging-confirmed adrenal cysts. The majority were female (75.3%) and more than half were white (55.8%). One-third of patients underwent ADX, and the remaining were observed. ADX patients were younger (median age [IQR]: 55.5 y [45.0-68.2 y] vs. 44.2 y [38.7-55.0 y], p = 0.01) and more likely to be Hispanic (12% vs. 0%, p = 0.05). ADX patients presented with larger cysts (5.6 vs. 2.6 cm, p = 0.002). The median time from diagnosis to last follow-up was 1.1 y for ADX and 4.1 y for OBS. Average growth for OBS was 0.3 cm/y, while average growth for ADX was 3.9 cm/y. In ADX patients, cysts >10 cm grew significantly faster than cysts <10 cm (median growth rate 13.2 cm/y vs. 0.3 cm/y, p < 0.05). There was no adrenal malignancy diagnosis, hyperfunctionality, or observation-related complications (e.g., rupture)., Conclusion: While size >4-6 cm has guided surgical referral for solid adrenal masses, this study demonstrates a size threshold of 10 cm, below which asymptomatic, simple adrenal cysts can safely be observed., (© 2024 International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC).)

Bilateral adrenal masses, increasingly encountered in clinical practice, manifest across diverse contexts, including incidental discovery, malignancy staging, and targeted imaging after hormonal diagnosis of adrenal disorders. The spectrum encompasses various pathologies, such as cortical adenomas, macronodular adrenal disease, pheochromocytomas, myelolipomas, infiltrative disorders, and primary and secondary malignancies. Notably, not all masses in both adrenal glands necessarily share the same etiology, often exhibiting diverse causes. Recently, the European Society of Endocrinology and the European Network for the Study of Adrenal Tumors updated guidelines, introduced a 4-option schema based on imaging, aiding in targeted hormonal testing and management. This "Approach to the Patient" review delves into the latest advancements in imaging, biochemical, and genetic approaches for the diagnostic and management nuances of bilateral adrenal masses. It provides insights and a contemporary framework for navigating the complexities associated with this clinical entity., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Endocrine Society. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: Although uncommon, adrenal hemorrhage has multiple etiologies. Because clinical characteristics, management, and outcomes of patients with adrenal hemorrhage are inadequately described, we examined the underlying etiology, need for intervention, evolution of imaging characteristics, and adequacy of subsequent evaluation., Methods: We performed a retrospective review of patients diagnosed with adrenal hemorrhage (radiologist-confirmed density consistent with hemorrhage on computed tomography) from 2005 to 2021 at a university-based institution. Demographic characteristics, hemorrhage etiology, and subsequent follow-up were analyzed., Results: Of 193 adrenal hemorrhage patients, the mean age was 49.2 ± 18.3 years, and 35% were female. Clinical presentations included trauma (47%), abdominal or flank pain (28%), incidental findings on imaging acquired for other reasons (12%), postoperative complication (8%), or shock (3%). Hemorrhage outside of the gland was present in 62% of patients. Unilateral hemorrhage was more frequent (93%) than bilateral (7%). A total of 12% of patients had nodules, but only 70% of these were identified on initial imaging, and only 43% had hormonal evaluation. Of 7 patients who had adrenalectomy or biopsy, pathology was either benign (57%) or nonadrenal malignancy (43%). No adrenocortical carcinomas were identified. Follow-up imaging was performed in 56% of patients and revealed decreased, stable, resolved, or increased adrenal hemorrhage size in 39%, 19%, 30%, and 12% of patients, respectively., Conclusion: Adrenal hemorrhage is secondary to multiple etiologies, most commonly trauma. In the setting of adrenal hemorrhage, many adrenal nodules were not identified on initial imaging. Only a minority of patients with nodules underwent "complete" biochemical evaluation. Follow-up imaging may improve the identification of underlying nodules needing hormonal evaluation., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Introduction: Adrenal hemorrhage (AH) is a rare condition and severe cases can lead to acute adrenal insufficiency with potentially life-threatening consequences. AH can be caused by a variety of etiologic factors, including systemic lupus erythematosus and antiphospholipid syndrome (APS). The early identification and treatment of these patients improves their prognosis., Objective: The aims of this study were to analyze and summarize the clinical characteristics of systemic lupus erythematosus patients with AH., Methods: The clinical characteristics of 6 systemic lupus erythematosus patients complicated with AH admitted to Peking Union Medical College Hospital and Beijing Shijitan Hospital from May 2004 to April 2022 were retrospectively analyzed., Results: The diagnosis of AH was based on computed tomography (CT) findings. Two patients had bilateral lesions, and the other 4 patients had unilateral lesions. The symptoms of adrenal insufficiency were observed in 2 patients. The frequent presenting symptoms were abdominal pain, lower abdominal distension, vomiting, weakness, fever, arthrodynia, and skin rash. Four patients had APS. Five patients (4 patients with APS and 1 patient without APS) had thromboembolic events. All patients received glucocorticoid and immunosuppressant therapy. Five patients were treated with anticoagulant therapy. Follow-up imaging examinations showed a partial or total regression of the lesions after treatment., Conclusions: In the proper clinical setting, having high clinical suspicion for AH, early diagnosis and timely management is crucial to avoid life-threatening adrenal insufficiency. Key Points • AH is a rare condition and severe cases may lead to death. It can be caused by a variety of etiologic factors, including SLE. • In patients with SLE, especially combined with APS, if they complain of abdominal pain, particularly when common gastrointestinal involvement is difficult to explain, a high index of clinical suspicion is needed for the diagnosis of AH. • Early identification of AH in SLE patients can improve their prognosis., (© 2024. The Author(s), under exclusive licence to International League of Associations for Rheumatology (ILAR).)

Neonatal adrenal haemorrhage (NAH) is more frequently described in neonates due to their relatively larger size and increased vascularity. While most are asymptomatic, they can present with anaemia, jaundice, abdominal mass, scrotal haematoma or more severe complications such as shock and adrenal insufficiency. Scrotal haematoma seen with NAH may be mistaken for other more serious conditions causing acute scrotum. Prompt sonographic examination that includes the bilateral adrenal glands may help to detect NAH early and to avoid unnecessary interventions. Cases of NAH causing ipsilateral inguinal ecchymosis and scrotal haematoma have been reported, but contralateral haematomas are very rare. In this report, we present a unique case of a neonate with an antenatally acquired adrenal haematoma complicated with an acute peripartum rebleeding manifesting as a contralateral scrotal haematoma and inguinal ecchymosis. The NAH was treated conservatively and resolved on follow-up imaging., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

Hirsutism is a relatively common disorder which affects approximately 5% to 15% of women. It is defined by excessive growth of terminal hair in women, which primarily affects areas dependent on androgens, such as the face, abdomen, buttocks, and thighs. Hirsutism can be caused by a variety of etiologies, which are most often not lifethreatening. However, in some cases, hirsutism can be an indicator of more serious underlying pathology, such as a neoplasm, which may require further elucidation with imaging. Within the abdomen and pelvis, adrenal and ovarian pathologies are the primary consideration. The goal of this manuscript is to review the etiologies and imaging features of various intra-abdominal and intra-pelvic causes of hirsutism., (© 2024. The Author(s).)

The incidence of adrenal cysts is 0.06% and only 9% of these are true mesothelial cysts. Here, we present a case of a true mesothelial cyst together with a review of the literature. A female in her 30s presented to the surgical outpatient department complaining of right flank pain. Her contrast-enhanced CT scan revealed a 7.5×6.5×4.5 cm right adrenal gland cyst. The patient underwent a laparoscopic right adrenalectomy. Immunohistopathology revealed the cyst to be mesothelial in nature. The majority of true mesothelial adrenal cysts are benign, unilateral and more common in women. Any adrenal cyst diagnosed as a functional lesion or one that may be malignant or with a diameter of 5 cm or greater requires surgical care whereas smaller lesions can be managed conservatively. Laparoscopic adrenalectomy for an adrenal cyst of diameter greater than 6 cm is a safe and feasible procedure in expert hands if there is no invasion of surrounding tissue., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Bilateral adrenal hemorrhage (BAH) is a rare condition that can lead to acute adrenal insufficiency and death if not recognized and treated promptly. We report the case of a 30-year-old male who presented to the emergency department with acute abdominal pain, nausea, and vomiting. On emergency room admission, the first abdominal CT revealed normal adrenal glands without enlargement, but with the development of hypotension and hypoglycemia, a second CT performed four days later showed enlargement due to hemorrhage in both adrenals. The diagnosis of BAH associated with acute adrenal insufficiency was retained. Prompt treatment with intravenous and oral corticosteroids resulted in successful conservative management. We describe the clinical, biological, radiological and etiological features of this condition based on a review of the literature., Competing Interests: The authors declare that they have no conflict of interest, (© Acta Gastro-Enterologica Belgica.)

Adrenal cysts are rare lesions representing approximately 1-2% of adrenal incidentalomas. The majority of these rare lesions are benign. Rarely, phaeochromocytomas and adrenal malignant masses can present as cystic lesions and can occasionally be difficult to distinguish from benign cysts. Histologically, adrenal cysts are subdivided into pseudocysts, endothelial cysts, epithelial cysts and parasitic cysts. The radiological appearance of an adrenal cyst is generally similar to that of cysts in the kidney. They are thus well demarcated, usually rounded, with a thin wall and homogenous internal structure, low attenuating (<20 Hounsfield Units) on CT, low signalling on T1-weighted MRI sequences and high signalling on T2-weighted MRI sequences, and anechoic or hypoechoic on ultrasonography. Benign adrenal cysts have a slight female predominance and are usually diagnosed between the ages of 40 and 60. Most adrenal cysts are asymptomatic and are detected incidentally, although very large adrenal cysts can lead to mass effect symptoms, with surgery required to alleviate the symptoms. Thus, conservative management is usually recommended for asymptomatic cysts. However, when uncertainty exists regarding the benign nature of the cyst, additional work-up or follow-up is needed. The management of an adrenal cyst should preferably be discussed at an adrenal multidisciplinary team meeting., (© 2023. Springer Nature Limited.)

Adrenal Gland Cysts are rare among all the pathologic cysts that occur in human beings; the pseudo-cyst variety even rarer. Adrenal pseudo-cysts are asymptomatic, non-functional, small, and incidentally discovered disease entities. Their clinical presentation is usually the result of their mass effects. Thanks to the advanced diagnostic technology, more such cases are being discovered timely and managed surgically, before life-threatening complications occur. Open surgical treatment remains the treatment of choice for giant cysts.

Cystic lesions of the adrenal glands are relatively uncommon and most of them are clinically silent. Though rarely associated with malignant changes, they may carry clinically detrimental consequences if misdiagnosed. Cystic adrenal lesions exhibit a broad histomorphological spectrum, ranging from pseudocysts, endothelial cysts, epithelial cysts and parasitic cysts. Here we present the case of a young woman with left-sided abdominal pain and contrast-enhanced CT showing a 10.4×7.7×7.8 cm fluid-filled left suprarenal lesion. The patient underwent exploratory laparotomy with cyst excision, and the histopathological examination of the specimen revealed a pseudocyst of the left adrenal gland. Despite being rare, usually benign and asymptomatic, the diagnosis and management of these cystic lesions of the adrenal glands are often unclear. Any functional lesion, potentially malignant lesion or lesion more than 5 cm deserves surgical management, whereas others can be managed conservatively., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

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A woman in her 40s attended the hospital with worsening left upper abdominal dull aching pain for the past 6 months. Clinical examination and radiological investigations with ultrasonography and contrast-enhanced CT of the abdomen confirmed it to be a cystic lesion of the left adrenal of size 13 cm × 12 cm × 11 cm. With the possibility of an incidental malignancy due to large size, laparoscopic cyst excision meticulously without spillage of cyst content was possible due to preoperative planning. It was a difficult task to mobilise the cyst intact due to the thin wall to prevent accidental rupture and gross spillage of the cyst contents. The cyst wall sent for histopathological examination confirmed it to be an adrenal pseudocyst without any malignant focus. Adrenal pseudocysts are rare and mostly benign. However, the index of suspecting a malignancy should be high in large cysts, and meticulous dissection is warranted., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Antiphospholipid syndrome (APS) is an uncommon autoantibody-mediated condition characterised by acquired thrombophilia resulting in recurrent arterial and venous thrombosis. An inciting factor allows for the exposure of endothelial phospholipids, causing antigen formation and subsequent creation of antibodies. A woman in her 70s presented after vehicular trauma, suffering broken ribs, pneumothorax and incidentally discovered left adrenal haemorrhage. Two weeks later she presented with acute-onset abdominal pain and was found to have a right adrenal gland haemorrhage on CT imaging without interval trauma occurring. The patient had antiphospholipid antibody laboratory studies drawn and was given intravenous heparin with a bridge to warfarin at discharge. Laboratory results returned positive for lupus anticoagulant, beta-2 glycoprotein and anticardiolipin antibodies indicating triple positivity, with repeated laboratory tests positive in 12 weeks' time, confirming the diagnosis. Bilateral adrenal haemorrhage, rather than traditional venous thromboembolism, was the presenting pathology in this patient's diagnosis of APS., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims: A focal lesion in the region of the adrenal gland in a newborn often requires further assessment. Ultrasound (US) is the initial imaging method of choice in young children as it does not use radiation or require sedation and it has excellent spatial resolution. In this case series, we present contrast-enhanced ultrasound (CEUS) as a problem-solving tool in the evaluation of neonatal adrenal lesions., Material and Methods: The imaging and medical records of five patients with adrenal lesions were retrospectively reviewed. All patients underwent US as an initial examination and all had US follow-up. Additionally, two patients had MRI examinations. CEUS was performed in all patients as a follow up examination. The enhancement characteristics of the adrenal masses on CEUS were analyzed with the use of VueBox software. In addition, qualitative analysis of the cine loops for the presence of vascularization within the lesions was performed by consensus between two radiologists., Results: The presence of an adrenal hematoma was correctly detected and characterized by CEUS in all five cases using VueBox perfusion analysis. Adrenal hematomas had no internal perfusion and flat time intensity curves., Conclusion: The quantitative and qualitative CEUS assessment of the mass can distinguish hemorrhage from a malignant lesion. Based on our findings, CEUS could serve as an alternative diagnostic tool to magnetic resonance imaging in the diagnosis of slowly resolving NAH lesions.

Adrenal cystic lesions are generally rare and encompass a wide spectrum of benign and malignant entities. Increased utilisation of cross-sectional imaging has led to increased detection of incidentally discovered adrenal lesions. Many of these lesions are cystic or solid with cystic changes, and the majority are benign; however, some may represent malignant lesions and/or even metastases. Therefore, it is vital to characterise these lesions appropriately and follow-up with laboratory tests and imaging if necessary. Key imaging techniques include computed tomography (CT) and magnetic resonance imaging (MRI). Other supplemental imaging tools include metaiodobenzyl-guanidine (MIBG) scintigraphy and 2-[ 18 F]-fluoro-2-deoxy-d-glucose positron-emission tomography (FDG-PET). Accurate diagnosis of adrenal cystic lesions is crucial in guiding appropriate evaluation and management of these patients. This review highlights the clinical presentations, pathological and imaging features, and management of cystic adrenal lesions., (Copyright © 2022 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Spontaneous adrenal haemorrhage (SAH) is a rare condition. The incidence of adrenal haemorrhage in pregnancy is currently not known; however, an association with pregnancy has been reported.An acute presentation with severe back or flank pain should raise suspicion of this condition. Diagnosis is based on imaging. An ultrasound scan is a basic and readily available investigation in pregnancy to rule out renal and suprarenal pathology while CT or MRI scan can help to confirm the diagnosis. A multidisciplinary team (MDT) approach, involving the obstetric, anaesthetic, medical and endocrine team, is essential in management of this condition.We present a case of an SAH; managed conservatively, in an otherwise healthy and low-risk pregnant woman and describe the literature review on this rare condition, including pathophysiology and management., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Neonatal adrenal hemorrhage (NAH) is an almost infrequent phenomenon (0.2-0.55%). Mechanical compression and alterations of venous pressure during delivery are considered the most probable explanations. Approximately 10% of the cases might have bilateral involvement. Clinical symptoms include abdominal mass, poor feeding, vomiting, prolonged jaundice, and anemia. Subgaleal hemorrhage (SGH) is one of the most clinically remarkable and potentially hazardous postnatal cranial injuries., Case Presentation: An early-term Iranian male neonate who was born through spontaneous vaginal delivery and experienced shoulder dystocia was diagnosed with bilateral NAH leading to adrenal insufficiency requiring glucocorticoid and mineralocorticoid supplementation. The SGH and jaundice were other postnatal complications. Serial monthly abdominal and brain ultrasound revealed complete regression of lesions after 70 days. However, after 16 months, the neonate has been still treated with hydrocortisone and fludrocortisone for the adrenal insufficiency diagnosis. He has a lower limit weight for age; however, developmental milestones have been appropriate for age., Discussion and Conclusion: Adrenal hemorrhage and SGH should be examined and looked for, particularly with proven evidence of difficult delivery and asphyxia in at-risk newborns. Clinical and ultrasound follow-up is mandatory for the assessment of hemorrhage resolution and conservative management. The early detection and treatment of adrenal insufficiency by laboratory examination is strongly recommended in bilateral cases. Furthermore, the early recognition of postnatal SGH to prevent clinical and neurological outcomes seems essential., (© 2022. The Author(s).)

BACKGROUND Adrenal gland cysts are rare and often occur without any symptoms. Even with advanced imaging modalities, it is still difficult to differentiate a benign adrenal neoplasm from a malignant one. Therefore, it is difficult to arrive at a definitive diagnosis and provide treatment. CASE REPORT We describe a patient with asymptomatic adrenal incidentaloma. The patient was lost to follow-up until 7 years later. On resuming follow-up, an enlarged suprarenal tumor was noted on ultrasound imaging. Magnetic resonance imaging revealed a 6×4 cm tumor mass, and the peripheral part expressed progressive enhancement on dynamic contrast-enhanced images. Laboratory data showed slight hypokalemia, and a complete endocrine assessment was performed, which showed no abnormality. Because malignancy of the adrenal gland remained suspected, a laparoscopic adenectomy was performed. The pathological result showed an adrenal endothelial (vascular) cyst with the formation of thrombi and calcification, without any evidence of malignancy. CONCLUSIONS Adrenal cystic lesions can change with time. Routine imaging studies during follow-up are recommended, and endocrine evaluations should be performed as an initial adrenal tumor work-up. Surgery is the treatment of choice when the cyst is >6 cm in size, malignancy is suspected, or abnormal endocrine activity is present.

TAFRO syndrome is a systemic inflammatory disorder resembling multicentric Castleman disease; it is characterized by thrombocytopenia, anasarca, a fever, reticulin fibrosis, and organomegaly. Involvement of the adrenal glands, including adrenal infarction, hemorrhaging, and adrenomegaly, has recently been reported in several cases and been considered a characteristic early-stage symptom. We herein report a case of TAFRO syndrome initially presenting with bilateral adrenal infarctions and review the literature on TAFRO syndrome related to adrenal involvement. This case suggests that adrenal abnormalities as an early clinical feature of TAFRO syndrome may be useful for the early diagnosis.

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Objective: The novel coronavirus disease 2019 (COVID-19) may affect the adrenal glands. Therefore, it is important to evaluate the morphologic appearance of the adrenal glands by thorax computed tomography (CT). On CT scans, stranding in peripheral fatty tissue with enlarged adrenal glands may indicate signs of adrenal infarction (SAI). The present study aimed to evaluate the incidence of SAI and determine whether this finding may contribute to predictions of the prognosis of COVID-19., Patients and Methods: A total of 343 patients who had been hospitalized at Malatya Training and Research Hospital between September 1 and 30, 2020, with a diagnosis of COVID-19 were enrolled in this study. All patients underwent thorax CT scans that included their adrenal glands., Results: Of the enrolled patients, 16.0% had SAI. Moreover, 41.8% of patients with SAI and 15.3% of patients without SAI were treated in the Intensive Care Unit (ICU). Patients with SAI had a significantly higher rate of ICU admission (p < 0.001). Mortality rates were also significantly higher among patients with SAI than those without p < 0.001)., Conclusions: In this study, it was found that COVID-19 patients with SAI may have a poorer prognosis. More comprehensive studies are needed on this subject, but the present study may provide helpful preliminary information in terms of prognosis.

Adrenal masses are frequently incidentally identified from cross-sectional imaging studies, which are performed for other reasons. The intensity of the approach to the patient with such a mass is tailored to the clinical situation, ranging from a quick evaluation to a detailed work-up. In all cases, the three components of the evaluation are clinical assessment, review of the images, and biochemical testing with the goal of ruling out malignancy and identifying hormonally active lesions. This article incorporates recent information to produce a logical, systematic assessment of these patients with risk stratification and proportionate follow-up., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Adrenal hemorrhage (AH) is a rare condition. It can be traumatic or non-traumatic. Most common causes are septicemia, coagulopathy or bleeding diathesis, and underlying neoplasms. Other reported less common causes of AH are COVID-19 and neonatal stress. Clinical diagnosis of AH is challenging due to its non-specific presentation and occurrence in the setting of acute medical illness. Therefore, most cases are diagnosed incidentally on imaging. Having high clinical suspicion in the proper clinical setting for AH is crucial to avoid life-threatening adrenal insufficiency that occurs in 16-50% of patients with bilateral AH. We discuss the clinical situations that predispose to AH, review the imaging features on different imaging modalities, highlight a variety of clinical cases, imaging features that should be concerning for an underlying neoplasm, and outline the potential role of interventional radiology in management of AH.

We report a 47-year-old male with a severe disease caused by COVID-19, who required mechanical ventilation for 18 ays. During the hospital stay he received dexamethasone and anticoagulation with heparin. After discharge a new chest CT scan showed homogeneous hypo vascular enlargement of both adrenal glands, not present in the initial imaging studies. It was interpreted as a subacute bilateral adrenal hemorrhage. The patient remained stable and without any complaint.

Immune checkpoint inhibitors (ICIs), a form of immunotherapy, are increasingly used for a variety of malignancies and have been linked to numerous treatment-related side effects known as immune-related adverse events (irAEs). IrAEs can affect multiple organ systems and are important to recognise in order to avoid misinterpretation as progressive tumour and to ensure appropriate management. In this pictorial review, we will briefly discuss radiological response criteria of immunotherapy and describe the imaging appearances of the wide spectrum of these ICI-associated toxicities., (Copyright © 2020 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Suprarenal or adrenal gland haemorrhage is an uncommon but potentially lethal condition if unrecognised. Adrenal masses rarely present with haemorrhage, but they remain an important differential aetiology for adrenal bleeding. We present a novel case of primary adrenal lymphoma with adrenal haemorrhage in a middle-aged woman who presented with right-sided abdominal pain and class 1 haemorrhagic shock. She was found to have spontaneous unilateral adrenal gland haemorrhage in the absence of any underlying previous pathology. Presenting features, diagnosis and subsequent oncological management are reported.

Objectives: To retrospectively investigate the incidence of acute adrenal infarction (AAI) in patients who underwent chest CT for severe SARS-CoV-2 infection and to correlate findings with prognosis., Methods: The local ethics committee approved this retrospective study and waived the need of informed consent. From March 9 to April 10, 2020, all patients referred to our institution for a clinical suspicion of COVID-19 with moderate to severe symptoms underwent a chest CT for triage. Patients with a/parenchymal lesion characteristics of COVID-19 involving at least 50% of lung parenchyma and b/positive RT-PCR for SARS-CoV-2 were retrospectively included. Adrenal glands were reviewed by two independent readers to look for AAI. Additional demographics and potential biological markers of adrenal insufficiency were obtained. Correlations with ICU stay and mortality were sought., Results: Out of the 219 patients with critical (n = 52) and severe lung (n = 167) parenchyma lesions, 51 (23%) had CT scan signs of AAI, which was bilateral in 45 patients (88%). Four patients had an acute biological adrenal gland insufficiency (8%). Univariate analysis in AAI+ patients demonstrated a higher rate of ICU stay (67% vs. 45%, p < 0.05) and a longer stay (more than 15 days for 31% for AAI+ vs. 19%, p < 0.05) compared with AAI- patients. Mortality rate was similar (27%, p = 0.92)., Conclusions: Acute adrenal infarction on initial chest evaluation of severe COVID-19 is frequent (51/219, 23%) and might be a sign of poorer prognosis., Key Points: • Acute adrenal infarction on initial chest CT evaluation of severe COVID-19 is frequent (51/219). • AAI might be a factor of poorer prognosis, with increased rate of ICU hospitalization and length of stay.

Although adrenal resection is a major option to control hypercortisolemia in patients with bilateral macronodular adrenal hyperplasia, a predictive method for postoperative cortisol production has not been established. A 53-year-old man with ulcerative colitis was referred to our hospital for bilateral multiple adrenal nodules and hypertension. Physical and endocrinological examination revealed inappropriate cortisol production and suppressed secretion of adrenocorticotropic hormone with no typical signs of Cushing's syndrome. Imaging analysis revealed bilateral adrenal nodular enlargement, the nodules of which had the radiological features of adrenocortical adenomas without inter-nodular heterogeneity. In addition, computed tomography volumetry demonstrated that the left adrenal gland (70 mL) accounts for three quarters of the total adrenal volume (93 mL). The patient was diagnosed as subclinical Cushing's syndrome due to bilateral macronodular adrenal hyperplasia, and subsequently underwent a left laparoscopic adrenalectomy with the estimation of 75% decrease in the cortisol level based on the adrenal volume. The surgical treatment ultimately resulted in control of the cortisol level within the normal range, which was compatible to our preoperative prediction. However, regardless of the sufficient cortisol level, ulcerative colitis was exacerbated after the surgery, which needed a systemic therapy for remission. This case indicates successful surgical control of hypercortisolemia based on computed tomography volumetry in bilateral macronodular adrenal hyperplasia, as well as the perioperative exacerbation risk for inflammatory diseases in Cushing's syndrome. We report the potential utility of computed tomography volumetry as a quantitative method with retrospective evaluation of our historical cases.

We report a case of adrenal extramedullary haematopoiesis in a 24-year-old women who presented with pallor and weakness. Ultrasonography of the abdomen detected moderate hepatosplenomegaly with multiple lesions in the spleen and an incidental right adrenal mass. There was no ascites or lymphadenopathy. CT scan revealed a heterogeneous right adrenal mass with multiple non-enhancing lesions in the spleen. Ultrasound guided trucut biopsy was performed after excluding a functioning tumour, which confirmed the diagnosis. Later, she was diagnosed to have haemoglobin E/beta thalassaemia and was put on hydroxyurea trial., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Adrenal Castleman disease is very rare. We reported image findings of a right adrenal mass in a 75-year-old man on Tc-HYNIC-TOC scan and FDG PET/CT. There was obviously elevated Tc-HYNIC-TOC activity, but the intensity of FDG activity was remarkable. Pheochromocytoma was initially suspected. However, pathology from resected specimen showed adrenal Castleman disease.