Department of Pediatric Surgery, Lady Hardinge Medical College and Kalawati Saran Children's Hospital,. New Delhi, India. Abstract. A 23-day-old male baby ...
C l i n i c a l Brief
Bilateral Adrenal Abscess in a Neonate Pinaki Ranjan Debnath, Rakesh Kumar Tripathi, Ajay Kumar Gupta, Rajiv Chadha and S. Roy Choudhury Department of Pediatric Surgery, Lady Hardinge Medical College and Kalawati Saran Children's 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. [Indian J Pediatr 2005; 72 (2) : 169-171] E-mail: rajiv__chadha_01 @yahoo. com Key words : Adrenal abscess; Adrenal hemorrhage; Neonate
Adrenal abscess in the neonatal period is a rare disease. ~a Steffens et al in 19972 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 o u t c o m e with d e l a y e d surgical therapy? 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.
internal echoes below the right lobe of the liver. A contrast e n h a n c e d a b d o m i n a l CT scan s h o w e d two encysted collections with enhancing rims in the suprarenal areas, the larger one on the right side and the smaller on the left side (Fig. 1). Both kidneys were enlarged, displaced downwards and showed calyceal dilatation (Fig. 2). There was hepatomegaly. A presumptive diagnosis of bilateral adrenal abscess was made. Afer taking a blood sample for b a c t e r i o l o g i c a l c u l t u r e , the child was s t a r t e d on i n t r a v e n o u s antibiotics- ampicillin, netilimycin and metronidazole. h,
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 b a b y had b e e n a d m i n i s t e r e d b r o a d - s p e c t r u m antibiotics (cefotaxime and amikacin) by a practitioner for the last 3 days. The child was a product of a full-term d e l i v e r y at a p e r i p h e r a l hospital. The birth h i s t o r y revealed prolonged, difficult labor, a history of meconium aspiration and delayed cry after birth. Examination revealed an active infant showing pallor a n d m o d e r a t e a b d o m i n a l distension. A b d o m i n a l examination showed hepatomegaly and a large cystic mass in the right u p p e r a b d o m e n . The s p l e e n 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) s h o w e d h e p a t o m e g a l y with h e t e r o g e n o u s liver architecture and a cystic mass 5.8 X 3.6 cm size containing
Correspondenceand Reprintrequests : Dr. Rajiv Chadha, G-123 Vikaspuri, New Delhi-ll0 018, India. Indian Journal of Pediatrics, Volume 72--February, 2005
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Fig. 1. Contrast-enhanced CT scan of the abdomen showing collectionswith enhancing rims in both suprarenal areas. The child became increasingly irritable with complete refusal of feeds o v e r the next 24 hours. Surgical exploration was therefore p e r f o r m e d 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 169
Pinaki Ranjan Debnath et al
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 d i s c h a r g e d after 10 d a y s of a n t i b i o t i c t h e r a p y . 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 n e e d to c o m e i m m e d i a t e l y to the h o s p i t a l if such symptoms appeared. At follow-up after 3 months, the child was doing well with no clinical signs or s y m p t o m s of a d r e n a l 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.
E. coli, ~,2,9 or Staph a u r e u s s,~~ but S t r e p t o c o c c u s , Bacteriodes, Echovirus and Herpes simplex could also be isolated. 1-s.7,~,nIn our patient, bacteriological studies were n e g a t i v e , p r o b a b l y b e c a u s e the b a b y had b e e n 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. ~2~ An early and accurate diagnosis of n e o n a t a l a d r e n a l abscess is essential to a v o i d a potentially lethal outcome, particularly in septic neonates like o u r patient. E x t e n s i o n of the abscess w i t h involvement of adjacent organs has been reported2 -s.lz~3A case of retroperitoneal p u l m o n a r y 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 diagnosis2 ~ At present, CT scan a n d / o r magnetic resonance imaging (MRI) should enable one to usually arrive at the correct preoperative diagnosis. 2Wells et al 1~documented a neonatal suprarenal abscess using Technetium-99m glucoheptonate imaging. The treatment of choice for neonatal adrenal abscess is drainage. Mondor et al ~ described successful drainage u s i n g a pigtail c a t h e t e r p l a c e d u n d e r s o n o g r a p h i c guidance. Antibiotic t h e r a p y was c o n t i n u e d 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 size2 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 h o w e v e r surgical d r a i n a g e . A r e t r o p e r i t o n e a l or thoracoabdominal approach has been described. 2 In our patient, the p r e s e n c e of bilateral adrenal abscesses necessitated a wide transverse abdominal incision.
DISCUSSION
CONCLUSION
Two theories have been proposed for the development of neonatal adrenal abscess: first, hematogenous bacterial seeding of a normal adrenal gland 3-s and second, the s e e d i n g of a n e o n a t a l a d r e n a l h e m o r r h a g e with s u b s e q u e n t abscess formation. 5,6 In some cases, the etiology may be unclear. 2,7It is likely that most adrenal abscesses begin with adrenal h e m o r r h a g e that is not i n f r e q u e n t l y associated with t r a u m a t i c or difficult delivery, hypoxia, sepsis and coagulopathy, s'6,s 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
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 d i a g n o s t i c aids. Early d i a g n o s i s and a p p r o p r i a t e t r e a t m e n t u s u a l l y lead to a successful outcome.
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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. SteffensJ, Zaubitzer T, Kirsch W, Humke U. Neonatal adrenal abscesses. Eur Urol 1997;31 : 347-349. 3. Catty A, Stanley P. Bilateral adrenal abscess in a neonate. Pediatr Radiol 1973; 1 : 63-64. Indian Journal of Pediatrics, Volume 72--February, 2005
Bilateral Adrenal Abscess in a Neonate 4. Gibbons MD, Duckett JW, Cromie WJ. Abdominal flank mass in the neonate. J Uro11978; 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. ] 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, G o e t z m a n n BW. A d r e n a l 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. A d r e n o b r o n c h i a l fistula complicating a neonatal adrenal
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abscess: treatment by percutaneous aspiration and antibiotics. Pediatr Radio11997; 27 : 184-185. Wells RG, Sty JR, Hodgson NB. Suprarenal abscess in the neonate- Technetium-99m G l u c o h e p t o n a t e imaging. Clin Nuclear Med 1986; 11 : 32-34. Ohta S, Shimizu S, Fujisawa S, Tsurusawa M. Neonatal adrenal abscess due to bacteroides. J Pediatr 1978; 93 : 1064-1065. Speer ME, Dawn DH.,F et al. ~-Iepatoadrenal necrosis in the neonate associated with echovirus type 11 and 12 presenting as a surgical emergency. J Pediatr Surg 1984; 19 : 591-593. B l a n k e n s h i p WJ, Bogren H, S t a d a l n i k RC, Vitale DE. Suprarenal abscess in the neonate: A case report and review of diagnosis and management. Pediatrics 1975; 55 : 239-243.
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