Adrenal hematoma simulating malignancy in ITP
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Published in the Journal of Current Surgery, the authors present a case of present a case of a patient with ITP (idiopathic thrombocytopenic purpura) and large adrenal mass suspicious for malignancy, which was surgically excised, and turned out to be an adrenal hematoma.

A 65-year-old female with history of hyperlipidemia, hypertension, diabetes mellitus, hypothyroidism, coronary artery disease, depression, tonsillectomy, cholecystectomy, tubal ligation, colonoscopy, and arthroscopy presented with lower gastrointestinal bleed, thrombocytopenia, weakness, petechial rash and easy bruising. She was diagnosed with ITP and was treated with steroids.

Her platelets count improved from 50 to 120 and she had colonoscopy with polypectomy. Three months later, she started to have abdominal pain in left upper quadrant (LUQ) radiating to her back. Abdominal computer tomography (CT) showed 7 × 9 × 6 cm left adrenal mass with calcifications and central and peripheral enhancement with IV contrast, highly suspicious for primary adrenal carcinoma or metastatic disease.

Comprehensive endocrinology evaluation, including plasma and urine aldosterone, plasma renin activity, plasma and urine metanephrines, plasma and urine catecholamines, free cortisol and dehydroepiandrosterone (DHEAS) did not show hormonally active adrenal tumor. There was no evidence of adrenal insufficiency. Radiological evaluation with CT of the neck, chest, abdomen and pelvis was negative for any primary malignancy. Indication for surgery was large mass suspicious for primary left adrenal carcinoma.

Patient underwent left adrenalectomy. Operation was started laparoscopically. During the procedure, significant desmoplastic reaction was noted around the mass with involvement of the splenic and left renal veins, and the case was converted to open. Final pathology evaluation of the excised mass showed organized adrenal hemorrhage with necrosis.

Patient had successful recovery and had no symptoms or recurrence for 2 years. Abdominal CT performed 24 months after surgery showed no evidence of recurrence.

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