Bilateral adrenal abscess in a neonate
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《美国医学杂志》
Department of Pediatric Surgery, Lady Hardinge Medical College and Kalawati Saran Childrens Hospital, New Delhi, India
Abstract
A 23-day-old male baby with a history of perinatal hypoxia presented with refusal of feeds and abdominal distension. The child had a right-sided cystic upper abdominal mass and features of neonatal septicemia. Abdominal ultrasound (US) and contrast-enhanced CT scan showed bilateral adrenal abscesses. Laparotomy with drainage of the abscesses successfully treated the condition. The literature on the subject is reviewed.
Keywords: Adrenal abscess; Adrenal hemorrhage; Neonate
Adrenal abscess in the neonatal period is a rare disease.[1],[2] Steffens et al in 1997[2] found that only 15 cases had been documented in the literature. Bilateral abscesses are even more uncommon.[3] Early and accurate diagnosis of the condition based on perinatal history, clinical examination and radiographic evaluation is essential because of the high rate of lethal outcome with delayed surgical therapy.[2] The authors report a case of bilateral adrenal abscess in a newborn, probably a consequence of perinatal adrenal hemorrhage. Laparotomy with drainage of the abscesses successfully treated the condition.
Case report
A 23-day-old male baby, weighing 3.4 kg was admitted for evaluation of decreased oral acceptance of feeds and increasing abdominal distension for the past 4 days. The child had been vomiting repeatedly for the past 2 days. The baby had been administered broad-spectrum antibiotics (cefotaxime and amikacin) by a practitioner for the last 3 days. The child was a product of a full-term delivery at a peripheral hospital. The birth history revealed prolonged, difficult labor, a history of meconium aspiration and delayed cry after birth.
Examination revealed an active infant showing pallor and moderate abdominal distension. Abdominal examination showed hepatomegaly and a large cystic mass in the right upper abdomen. The spleen was palpable 2 cm below the costal margin. Initial laboratory data was as follows: hemoglobin 10.7 g/dl, WBC count 12,620/cu.mm with 55% neutrophils, 28% lymphocytes, and 16% monocytes. Clotting tests, renal function tests and urine examination were normal. Ultrasonogram (US) showed hepatomegaly with heterogenous liver architecture and a cystic mass 5.8 X 3.6 cm size containing internal echoes below the right lobe of the liver. A contrast enhanced abdominal CT scan showed two encysted collections with enhancing rims in the suprarenal areas, the larger one on the right side and the smaller on the left side Figure1. Both kidneys were enlarged, displaced downwards and showed calyceal dilatation Figure2. There was hepatomegaly. A presumptive diagnosis of bilateral adrenal abscess was made. Afer taking a blood sample for bacteriological culture, the child was started on intravenous antibiotics- ampicillin, netilimycin and metronidazole.
The child became increasingly irritable with complete refusal of feeds over the next 24 hours. Surgical exploration was therefore performed by a transverse abdominal incision. The right suprarenal abscess drained 50 ml of thick pus while the left one drained around 25 ml pus. Specimens were sent for bacteriological culture. Tube drains were placed in the abscess cavities and a small specimen of tissue from the wall of the right adrenal abscess was sent for histological examination. Recovery was rapid with complete resolution of symptoms within 72 hours. Following cessation of drainage, the tube drains were removed 5 days after the surgery. The child was discharged after 10 days of antibiotic therapy. Bacteriological cultures were negative while histological examination showed acute and chronic inflammation in the abscess wall along with presence of adrenal tissue. There was no clinical evidence of adrenal insufficiency. However, the parents were counseled regarding features of adrenal insufficiency, especially during stress, and the need to come immediately to the hospital if such symptoms appeared.
At follow-up after 3 months, the child was doing well with no clinical signs or symptoms of adrenal insufficiency. Repeat serial US showed gradual regression of the residual abscess cavities as well as resolution of the hepatomegaly and the enlargement of the kidneys.
Discussion
Two theories have been proposed for the development of neonatal adrenal abscess: first, hematogenous bacterial seeding of a normal adrenal gland[3],[4],[5] and second, the seeding of a neonatal adrenal hemorrhage with subsequent abscess formation.[5],[6] In some cases, the etiology may be unclear.[2],[7] It is likely that most adrenal abscesses begin with adrenal hemorrhage that is not infrequently associated with traumatic or difficult delivery, hypoxia, sepsis and coagulopathy.[5],[6],[8] In our patient, there was a history of difficult and prolonged labor with perinatal hypoxia. The baby presented with pallor and an upper abdominal mass. All these features suggest that the adrenal abscesses resulted from bacterial seeding of neonatal adrenal hemorrhage. The presence of hepatosplenomegaly with enlarged, edematous kidneys also suggested neonatal septicemia. In most reported cases, bacterial examination of abscess material revealed E. coli,[1],[2],[9] or Staph aureus[8],[10] but Streptococcus, Bacteriodes, Echovirus and Herpes simplex could also be isolated.[1],[5],[7],[11],[12] In our patient, bacteriological studies were negative, probably because the baby had been administered potent broad-spectrum antibiotics prior to presentation at our center.
Differential diagnosis of adrenal abscesses includes adrenal hemorrhage, cyst, neuroblastoma, Wilm's tumor, renal duplication with dilatation of the upper segment and hydronephrosis.[1],[2],[5] An early and accurate diagnosis of neonatal adrenal abscess is essential to avoid a potentially lethal outcome, particularly in septic neonates like our patient. Extension of the abscess with involvement of adjacent organs has been reported.[1],[5],[12],[13] A case of retroperitoneal pulmonary fistula caused by a neonatal adrenal abscess has also been reported.[9] In earlier reports, US and intravenous pyelography (IVP) were shown to be useful for diagnosis.[1],[5] At present, CT scan and/or magnetic resonance imaging (MRI) should enable one to usually arrive at the correct preoperative diagnosis.[2] Wells et al[10] documented a neonatal suprarenal abscess using Technetium-99m glucoheptonate imaging.
The treatment of choice for neonatal adrenal abscess is drainage. Mondor et al[1] described successful drainage using a pigtail catheter placed under sonographic guidance. Antibiotic therapy was continued for two weeks. The authors stressed the need to closely follow up the patient by regularly repeated sonography until the adrenal gland is back to normal size.[1] Le Pointe et al[9] also described needle aspiration with antibiotic cover as definitive treatment for neonatal adrenal abscess. The mainstay of treatment, especially for large lesions or where differentiation from a malignant lesion is difficult is however surgical drainage. A retroperitoneal or thoracoabdominal approach has been described.[2] In our patient, the presence of bilateral adrenal abscesses necessitated a wide transverse abdominal incision.
Conclusion
Although neonatal suprarenal abscess is uncommon, it should be kept in mind as a differential diagnosis in septicemic newborns who present with a mass lesion in the suprarenal area, and especially in those neonates who have a history of perinatal hypoxia. US, CT scan and MRI are essential diagnostic aids. Early diagnosis and appropriate treatment usually lead to a successful outcome.
References
1. Mondor C, Gauthier M, Garel L, Filiatrault D, Grignon A. Nonsurgical management of neonatal adrenal abscess. J Pediatr Surg 1988; 23: 1048-1050.
2. Steffens J, Zaubitzer T, Kirsch W, Humke U. Neonatal adrenal abscesses. Eur Urol 1997; 31: 347-349.
3. Carty A, Stanley P. Bilateral adrenal abscess in a neonate. Pediatr Radiol 1973; 1: 63-64.
4. Gibbons MD, Duckett JW, Cromie WJ. Abdominal flank mass in the neonate. J Urol 1978; 119: 671-677.
5. Atkinson GO, Kodroff MB, Gay BB, Ricketts RR. Adrenal abscess in the neonate. Radiology 1985; 155: 101-104.
6. Favara BE, Akers DR, Franciosi RA. Adrenal abscess in a neonate. J Pediatr 1970; 77: 682-685.
7. Bekdash BA, Slim MS. Adrenal abscess in a neonate due to gas forming organisms: Diagnostic dilemma. Z Kinderchir 1981; 32: 184-187.
8. Rajani K, Shapiro SR, Goetzmann BW. Adrenal abscess: complication of supportive therapy of adrenal hemorrhage in the newborn. J Pediatr Surg 1980; 15: 676-678.
9. Le Pointe HD, Osika E, Montague JP, Tournier G, Sebbouh D. Adrenobronchial fistula complicating a neonatal adrenal abscess: treatment by percutaneous aspiration and antibiotics. Pediatr Radiol 1997; 27: 184-185.
10. Wells RG, Sty JR, Hodgson NB. Suprarenal abscess in the neonate- Technetium-99m Glucoheptonate imaging. Clin Nuclear Med 1986; 11: 32-34.
11. Ohta S, Shimizu S, Fujisawa S, Tsurusawa M. Neonatal adrenal abscess due to bacteroides. J Pediatr 1978; 93: 1064-1065.
12. Speer ME, Dawn DH. F et al. Hepatoadrenal necrosis in the neonate associated with echovirus type 11 and 12 presenting as a surgical emergency. J Pediatr Surg 1984; 19: 591-593.
13. Blankenship WJ, Bogren H, Stadalnik RC, Vitale DE. Suprarenal abscess in the neonate: A case report and review of diagnosis and management. Pediatrics 1975; 55: 239-243.(Debnath Pinaki Ranjan, Tr)
Abstract
A 23-day-old male baby with a history of perinatal hypoxia presented with refusal of feeds and abdominal distension. The child had a right-sided cystic upper abdominal mass and features of neonatal septicemia. Abdominal ultrasound (US) and contrast-enhanced CT scan showed bilateral adrenal abscesses. Laparotomy with drainage of the abscesses successfully treated the condition. The literature on the subject is reviewed.
Keywords: Adrenal abscess; Adrenal hemorrhage; Neonate
Adrenal abscess in the neonatal period is a rare disease.[1],[2] Steffens et al in 1997[2] found that only 15 cases had been documented in the literature. Bilateral abscesses are even more uncommon.[3] Early and accurate diagnosis of the condition based on perinatal history, clinical examination and radiographic evaluation is essential because of the high rate of lethal outcome with delayed surgical therapy.[2] The authors report a case of bilateral adrenal abscess in a newborn, probably a consequence of perinatal adrenal hemorrhage. Laparotomy with drainage of the abscesses successfully treated the condition.
Case report
A 23-day-old male baby, weighing 3.4 kg was admitted for evaluation of decreased oral acceptance of feeds and increasing abdominal distension for the past 4 days. The child had been vomiting repeatedly for the past 2 days. The baby had been administered broad-spectrum antibiotics (cefotaxime and amikacin) by a practitioner for the last 3 days. The child was a product of a full-term delivery at a peripheral hospital. The birth history revealed prolonged, difficult labor, a history of meconium aspiration and delayed cry after birth.
Examination revealed an active infant showing pallor and moderate abdominal distension. Abdominal examination showed hepatomegaly and a large cystic mass in the right upper abdomen. The spleen was palpable 2 cm below the costal margin. Initial laboratory data was as follows: hemoglobin 10.7 g/dl, WBC count 12,620/cu.mm with 55% neutrophils, 28% lymphocytes, and 16% monocytes. Clotting tests, renal function tests and urine examination were normal. Ultrasonogram (US) showed hepatomegaly with heterogenous liver architecture and a cystic mass 5.8 X 3.6 cm size containing internal echoes below the right lobe of the liver. A contrast enhanced abdominal CT scan showed two encysted collections with enhancing rims in the suprarenal areas, the larger one on the right side and the smaller on the left side Figure1. Both kidneys were enlarged, displaced downwards and showed calyceal dilatation Figure2. There was hepatomegaly. A presumptive diagnosis of bilateral adrenal abscess was made. Afer taking a blood sample for bacteriological culture, the child was started on intravenous antibiotics- ampicillin, netilimycin and metronidazole.
The child became increasingly irritable with complete refusal of feeds over the next 24 hours. Surgical exploration was therefore performed by a transverse abdominal incision. The right suprarenal abscess drained 50 ml of thick pus while the left one drained around 25 ml pus. Specimens were sent for bacteriological culture. Tube drains were placed in the abscess cavities and a small specimen of tissue from the wall of the right adrenal abscess was sent for histological examination. Recovery was rapid with complete resolution of symptoms within 72 hours. Following cessation of drainage, the tube drains were removed 5 days after the surgery. The child was discharged after 10 days of antibiotic therapy. Bacteriological cultures were negative while histological examination showed acute and chronic inflammation in the abscess wall along with presence of adrenal tissue. There was no clinical evidence of adrenal insufficiency. However, the parents were counseled regarding features of adrenal insufficiency, especially during stress, and the need to come immediately to the hospital if such symptoms appeared.
At follow-up after 3 months, the child was doing well with no clinical signs or symptoms of adrenal insufficiency. Repeat serial US showed gradual regression of the residual abscess cavities as well as resolution of the hepatomegaly and the enlargement of the kidneys.
Discussion
Two theories have been proposed for the development of neonatal adrenal abscess: first, hematogenous bacterial seeding of a normal adrenal gland[3],[4],[5] and second, the seeding of a neonatal adrenal hemorrhage with subsequent abscess formation.[5],[6] In some cases, the etiology may be unclear.[2],[7] It is likely that most adrenal abscesses begin with adrenal hemorrhage that is not infrequently associated with traumatic or difficult delivery, hypoxia, sepsis and coagulopathy.[5],[6],[8] In our patient, there was a history of difficult and prolonged labor with perinatal hypoxia. The baby presented with pallor and an upper abdominal mass. All these features suggest that the adrenal abscesses resulted from bacterial seeding of neonatal adrenal hemorrhage. The presence of hepatosplenomegaly with enlarged, edematous kidneys also suggested neonatal septicemia. In most reported cases, bacterial examination of abscess material revealed E. coli,[1],[2],[9] or Staph aureus[8],[10] but Streptococcus, Bacteriodes, Echovirus and Herpes simplex could also be isolated.[1],[5],[7],[11],[12] In our patient, bacteriological studies were negative, probably because the baby had been administered potent broad-spectrum antibiotics prior to presentation at our center.
Differential diagnosis of adrenal abscesses includes adrenal hemorrhage, cyst, neuroblastoma, Wilm's tumor, renal duplication with dilatation of the upper segment and hydronephrosis.[1],[2],[5] An early and accurate diagnosis of neonatal adrenal abscess is essential to avoid a potentially lethal outcome, particularly in septic neonates like our patient. Extension of the abscess with involvement of adjacent organs has been reported.[1],[5],[12],[13] A case of retroperitoneal pulmonary fistula caused by a neonatal adrenal abscess has also been reported.[9] In earlier reports, US and intravenous pyelography (IVP) were shown to be useful for diagnosis.[1],[5] At present, CT scan and/or magnetic resonance imaging (MRI) should enable one to usually arrive at the correct preoperative diagnosis.[2] Wells et al[10] documented a neonatal suprarenal abscess using Technetium-99m glucoheptonate imaging.
The treatment of choice for neonatal adrenal abscess is drainage. Mondor et al[1] described successful drainage using a pigtail catheter placed under sonographic guidance. Antibiotic therapy was continued for two weeks. The authors stressed the need to closely follow up the patient by regularly repeated sonography until the adrenal gland is back to normal size.[1] Le Pointe et al[9] also described needle aspiration with antibiotic cover as definitive treatment for neonatal adrenal abscess. The mainstay of treatment, especially for large lesions or where differentiation from a malignant lesion is difficult is however surgical drainage. A retroperitoneal or thoracoabdominal approach has been described.[2] In our patient, the presence of bilateral adrenal abscesses necessitated a wide transverse abdominal incision.
Conclusion
Although neonatal suprarenal abscess is uncommon, it should be kept in mind as a differential diagnosis in septicemic newborns who present with a mass lesion in the suprarenal area, and especially in those neonates who have a history of perinatal hypoxia. US, CT scan and MRI are essential diagnostic aids. Early diagnosis and appropriate treatment usually lead to a successful outcome.
References
1. Mondor C, Gauthier M, Garel L, Filiatrault D, Grignon A. Nonsurgical management of neonatal adrenal abscess. J Pediatr Surg 1988; 23: 1048-1050.
2. Steffens J, Zaubitzer T, Kirsch W, Humke U. Neonatal adrenal abscesses. Eur Urol 1997; 31: 347-349.
3. Carty A, Stanley P. Bilateral adrenal abscess in a neonate. Pediatr Radiol 1973; 1: 63-64.
4. Gibbons MD, Duckett JW, Cromie WJ. Abdominal flank mass in the neonate. J Urol 1978; 119: 671-677.
5. Atkinson GO, Kodroff MB, Gay BB, Ricketts RR. Adrenal abscess in the neonate. Radiology 1985; 155: 101-104.
6. Favara BE, Akers DR, Franciosi RA. Adrenal abscess in a neonate. J Pediatr 1970; 77: 682-685.
7. Bekdash BA, Slim MS. Adrenal abscess in a neonate due to gas forming organisms: Diagnostic dilemma. Z Kinderchir 1981; 32: 184-187.
8. Rajani K, Shapiro SR, Goetzmann BW. Adrenal abscess: complication of supportive therapy of adrenal hemorrhage in the newborn. J Pediatr Surg 1980; 15: 676-678.
9. Le Pointe HD, Osika E, Montague JP, Tournier G, Sebbouh D. Adrenobronchial fistula complicating a neonatal adrenal abscess: treatment by percutaneous aspiration and antibiotics. Pediatr Radiol 1997; 27: 184-185.
10. Wells RG, Sty JR, Hodgson NB. Suprarenal abscess in the neonate- Technetium-99m Glucoheptonate imaging. Clin Nuclear Med 1986; 11: 32-34.
11. Ohta S, Shimizu S, Fujisawa S, Tsurusawa M. Neonatal adrenal abscess due to bacteroides. J Pediatr 1978; 93: 1064-1065.
12. Speer ME, Dawn DH. F et al. Hepatoadrenal necrosis in the neonate associated with echovirus type 11 and 12 presenting as a surgical emergency. J Pediatr Surg 1984; 19: 591-593.
13. Blankenship WJ, Bogren H, Stadalnik RC, Vitale DE. Suprarenal abscess in the neonate: A case report and review of diagnosis and management. Pediatrics 1975; 55: 239-243.(Debnath Pinaki Ranjan, Tr)