Adrenal hemorrhagic pseudocyst: an unusual presentation
The present case has been reported in the journal Urology Case Reports.

A 56 year old male presented with on and off symptoms of pain of six months duration. The severity of the pain was mild to moderate and was not associated with hematuria. The patient was a known hypertensive and was on calcium channel blockers for the same. Patient was also a known diabetic on treatment.

US abdomen revealed a well-defined solid cystic mass measuring 8.2 in the region of right suprarenal gland pushing the right kidney downwards. The fat planes were preserved and the lesion showed mild vascularity on Doppler study. Twenty four hour urinary excretion of vanillyl mandelic acid (VMA) was 44.60 mg (four times the normal values).

CT revealed a well-defined lobulated solid-cystic heterogeneously enhancing mass lesion in the right suprarenal region measuring 7.7 6.9  cms. The right adrenal gland was not seen separately from this lesion. It was abutting the duodenum and IVC (inferior vena cava) medially, right crura of diaphragm posteriorly, segment I and V of the liver superiorly. Fat planes between the lesion and right kidney were maintained.

The patient was started on other anti-hypertensive drugs (alpha and beta blockers) and treated conservatively for about one week. In view of the raised urinary VMA levels, hypertension and the lesion in the right adrenal gland, the patient was advised right adrenalectomy. Patient was explored through a right loin incision and the lesion exposed. The lesion appeared like a mass of hemorrhagic pseudocysts with clotted blood within.

The mass was dissected out and excised. The intra-operative and post-operative period was uneventful. On repeated questioning in the post-operative period, the patient gave a history of a trivial fall from a two-wheeler about six months prior and sustained blunt injury to the chest, loin and upper abdomen on the right side. The patient then had taken pain killers on the advice of a local doctor.

The patient was discharged on the 5th post-operative day with advice of continuing anti-hypertensives. Histopathological examination of the surgical specimen revealed a pheochromocytoma. The alpha blocker was discontinued a week later and the patient's blood pressure was well controlled and maintained. Urinary VMA repeated three months later was within the normal range.

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