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Paracoccidioidomycosis is a systemic fungal infection caused by Paracoccidioides brasiliensis and endemic in certain areas of Central and South America. We report a case of a 62-year-old-man with a complex history of tuberculosis and imaging findings of a cerebral lesion and bilateral adrenal enlargement. Biopsy of adrenal gland revealed Paracoccidioides brasiliensis. This case highlights the importance of travel history for diagnosis of paracoccidioidomycosis in non-endemic areas and emphasizes the clinical and histopathological similarities with tuberculosis.

Selye’s article (Selye, 1936a) published in “Nature” has been enormously cited and markedly affected the entire field of “stress”, until today. The key concept of Selye’s stress theory was “the principle of nonspecificity”. Selye defined stress as the nonspecific responses of the body to various noxious agents. He gave various noxious stimuli to rats, and reported the results in his paper (Selye, 1936b). However, he described only raw data (thymus, and adrenal weights in individual rats), without even the mean values. This study analyzed those data statistically. Among his data, the result pattern most frequently observed was the both occurrences of thymus involution and adrenal enlargement. It appeared to give a conclusive evidence for Selye’s theory. However, there were also other two result patterns. The second pattern was a significant decrease in the thymus weight without changes in the adrenal weight (fasting for 24 - 96 hours in 3-month-old rats, morphine injections, and skin lesions). The third pattern was no change in either the thymus or adrenal weight (exposure to heat and bone fractures). These results disproved Selye’s theory of nonspecificity and they forsook it. And moreover, it was suggested that Selye’s results themselves supported Mason’s proposal that all stress responses were elicited through psychological emotional reactions (Mason, 1971), which were very compatible with the recent psychological stress theories.

Aim To assess the prevalence and the department's detection rate of adrenocortical hyperplasia. Materials and methods All computed tomography (CT) examinations of the adrenal glands between February and April 2011 were reviewed. The study excluded patients with known underlying cancer, abdominal trauma, or endocrine disease. The adrenal gland was deemed enlarged if its body was greater than 10 mm diameter, or a limb greater than 5 mm. Results There were a total of 564 eligible CT studies during this period. A total of 64 cases of incidental adrenal enlargement were found giving a prevalence of 11.3%. Only nine cases were reported in the contemporaneous CT report. Conclusion The results of the present study show that incidental adrenal enlargement has a significant prevalence. It is often dismissed during reporting, and awareness needs to be raised in the radiological community. Equally, the clinical and biochemical significance needs to be assessed with endocrine correlation.

Introduction: Evaluating the adrenal glands for size is fundamental in their imaging and to ascertain its normality or abnormality. Awareness of the range of normal size and shape is useful for adequate interpretation of computed tomography (CT) scans in patients with suspected adrenal pathology. Material and Methods: CT body scans of 1250 patients without evidence of adrenal disease were reviewed to determine the shape and size of normal adrenal glands. Patients with conditions that are known to affect the adrenal glands or any known malignancy were excluded from the study. Furthermore, patients with any evidence of focal adrenal enlargement or malignancy on imaging were not included in the study. All measurements were made on 64-slice contrast-enhanced CT axial sections and only those images were selected in which the adrenals were adequately visualized. Three measurements were made: maximum width of the body of the gland and maximum width of both the limbs (medial and lateral); all measurements were taken perpendicular to the long axis of the body/limb. Results: Based on our study, we came to the conclusion that the average width of the body of the right and left adrenal glands is 6.9 ± 0.31 mm and 5.4 ± 0.24 mm, respectively (though maximum width of the body may reach up to 11 mm) and that normal adrenal limbs should not measure >5 mm. Discussion and Conclusion: The most common shape of the adrenal glands was found to be Y shape, followed by the V and triangular shapes. The values provided in the present study may be used as a reference standard for the CT evaluation of the adrenal glands in the Indian population in particular.

SummaryObjective Although previous studies have shown enlargement of adrenal glands in patients with tuberculosis, only few have studied its natural history. Similarly, there have been variable reports of adrenal function in these patients. Some but not all the studies revealed a high prevalence of adrenal insufficiency. The aim of this study was to prospectively study the adrenal cortical function and morphology before and after treatment of pulmonary tuberculosis. Design and Patients In a prospective case–control study, 45 patients with acute pulmonary tuberculosis and 45 healthy age- and gender-matched controls were studied. Adrenal function was tested using a short Synacthen test at the baseline and after 6 months of antitubercular treatment. Size of both adrenal glands was studied using 64 slice MDCT (Somatom Sensation, Siemens) before and after 6 months of antitubercular treatment. The findings were compared with a group of healthy controls. Results The mean age of cases was 42·4 ± 20·4 years and that of controls was 41·1 ± 17·7 years. The various clinical and biochemical parameters were comparable between cases and controls. The mean cortisol both basal and one-hour postintravenous Synacthen was significantly lower in cases as compared to controls (mean ± SD basal cortisol of 413·57 ± 108·42 nmol/l in cases vs 615·26 ± 108·15 nmol/l in controls and post Synacthen cortisol of 685·61 ± 83·87 nmol/l in cases vs 1497·30 ± 734·44 nmol/l in controls). Both the adrenal length and thickness of the right and left adrenal gland were greater in patients with active tuberculosis compared with controls and reversed to baseline after completion of antitubercular treatment. Conclusion Adrenal enlargement demonstrated by CT is common in active tuberculosis and is reversible. Basal and stimulated cortisol is less in patients with pulmonary tuberculosis as compared with healthy controls and increases after antitubercular treatment, although unlike previous studies, none of the patients had adrenal insufficiency.

The intravascular variant of diffuse large B-cell lymphoma (IVBL) is a rare form of non-Hodgkin lymphoma that is frequently diagnosed at autopsy because the symptoms are nonspecific or confusing. We report a case of IVBL in a woman with pre-existing myelodysplastic syndrome manifested as a fever of unknown origin, bilateral adrenal enlargement and subsequent development of panhypopituitarism. Lymphomatous infiltration or osteomyelitis of the sella was supposed. Despite antibiotic and corticosteroid therapy the patient died within three months. An intravascular variant of B-cell lymphoma with intravascular collections of lymphomatous cells predominantly localized in the adrenal and pituitary glands was found at autopsy. The association of panhypopituitarism with bilateral adrenal enlargement is uncommon in endocrinological praxis and the occurrence of combined endocrine involvement in a patient with IVBL has not been described in previous literature.

In patients with cancer, adrenal enlargement due to either metastatic disease or diffuse non-metastatic hyperplasia is increasingly recognized with modern imaging techniques. Dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, characterized by non-suppressible hypercortisolism, has also been described in neoplasia in the absence of ectopic adrenocorticotrophic hormone (ACTH) production. In the majority of cases of malignancy-associated hypercortisolism, it might be expected that the presence of malignant disease would be clinically apparent, thus rendering a detailed endocrinological evaluation of the HPA axis unnecessary. However, in the present case we describe a patient with occult malignancy presenting with bilateral adrenocortical enlargement and non-suppressible hypercortisolism that was not due to the ectopic ACTH syndrome. There were no clinical Cushingoid features other than hypertension and new-onset diabetes mellitus. Detailed diagnostic investigations for the possibility of Cushing's syndrome were performed before the underlying diagnosis of gastric adenocarcinoma eventually became apparent. Characteristics and potential mechanisms of non-suppressible hypercortisolism in cancer are discussed. We believe that this scenario will occur with greater frequency in the future, given the increasing early use of sophisticated high-resolution imaging for the evaluation of suspected intra-abdominal pathology.

Key Clinical Message A rare cause for rapid adrenal enlargement is adrenal oncocytoma of uncertain malignant potential. A full biochemical evaluation is warranted to screen secreting adrenal adenomas as well as to evaluate adrenal cortical carcinoma. Careful pathologic evaluation is required as the diagnosis of AOC cannot be made by imaging.

To describe a patient with adrenal insufficiency and bilateral adrenal enlargement and to review causes of adrenal insufficiency, with special emphasis on adrenal hemorrhage.We present the clinical course of a woman with apparent septic shock, who responded poorly to treatment with inotropic agents. The possible cause and management of such cases are discussed.A 44-year-old woman with no prior major illness required medical attention because of severe hypotension, volume depletion, acute renal failure, and shock. Numerous laboratory and radiologic studies were performed to determine the cause of her shock state. She did not respond to several inotropic agents. When she was found to have adrenal insufficiency, initiation of treatment with glucocorticoids promptly alleviated her hypotension.Critically ill patients who have sudden unexplained hypotension that does not respond to supportive management should be screened for adrenal insufficiency. The current patient emphasizes the importance of considering this disorder in the differential diagnosis of hypotension that is unresponsive to pressor agents.

Inresponse to the first comment regarding the exclusioncriteria, we did not specifically exclude patients withdepression, as this information is rarely available in theacute setting. In addition, we did not feel it was appropriateto exclude inflammatory causes or infection of the adrenalglands if this was not the original presenting feature. Ourpaper focused on reporting the prevalence of adrenal hy-perplasia of unknown aetiology at presentation. We intendto follow these patients up in the long term to report theunderlying diseases. We excluded patients with knownbiochemical and clinical endocrine adrenal disease.Ourevaluationoftheimagingwasdoneaftertheoriginalcomputed tomography (CT) reports had been generated forclinical purposes. Regarding the pattern of disease, weassigned smooth adrenal hyperplasia when no adrenalnodules were present in either gland. Nodular adrenalhyperplasia was assigned when any nodules were seen.Hence, we did not report a mixed pattern as a separateentity. Adrenal nodules interspersed with smooth enlarge-ment have been reported as a “mixed” pattern in the liter-ature, which we included in within our nodular category.For the purpose of this paper we did not report interob-server variability as the data were analysed by two radiol-ogists with a final consensus opinion.

This study was designed to evaluate the sensitivity, specificity, and predictive accuracy of PET-FDG imaging in detecting metastatic disease involvement of adrenal glands in patients with lung cancer. We wanted to compare efficacy of positron emission tomography (PET)-fluorodeoxyglucose (FDG) imaging to computed tomography (CT) scanning in differentiating benign from malignant involvement of adrenal glands in patients with lung cancer. Thirty patients with biopsy-proven lung cancer and abnormal findings on PET and/or CT scanning were studied for presence of adrenal abnormality suggestive of metastatic disease involvement (n = 26) or benign adrenal enlargement (n = 4). The results of PET and CT scanning were compared to histological findings and/or clinical follow-up for at least 1 year for presence or absence of adrenal metastases. PET-FDG imaging correctly detected the presence of metastatic involvement in 17 of 18 patients and excluded metastatic involvement in 11 of 12 patients for sensitivity, specificity, and accuracy of 94.4%, 91.6%, and 93.3%, respectively. CT scanning showed enlarged adrenals without metastases in 8 of 30 patients and normal-sized adrenals in the presence of metastases in 5 of 30 patients. There was a false-positive PET finding in 1 patient and a false-negative PET finding in another patient. PET-FDG imaging is a highly sensitive, specific, and accurate test to differentiate benign from malignant involvement of adrenal glands in patients with lung cancer and often ambiguous findings on CT scanning.

A 61-year-old woman developed atraumatic bilateral adrenal hemorrhages while on anticoagulation. CT and MRI scans demonstrated enlarged adrenals with typical hemorrhagic features. Sequential CT scans showed gradual resolution of adrenal enlargement. Four months after the bleed, PET/CT was d

We describe a case of a female with simple virilizing congenital adrenal hyperplasia (CAH) reared as a male diagnosed at the late age of 64. Computed Tomography (CT) demonstrated a large adrenal mass, bilateral diffuse adrenal enlargement, female pelvic organs as well as a clearly visualized prostate gland. This is to the best of our knowledge the first case of such a sizable prostate gland in a female CAH patient documented on CT. We review the literature regarding aspects where radiologists may encounter CAH and the finding of presence of a prostate gland in female CAH patients.

The first part of the study aimed to describe prospectively the ultrasonographic features of the adrenal glands in 94 healthy cats and 51 chronically sick cats. It confirmed the feasibility of ultrasonography of adrenal glands in healthy and chronically sick cats, which were not statistically different. The typical hypoechoic appearance of the gland surrounded by hyperechoic fat made it recognisable. A sagittal plane of the gland, not in line with the aorta, may be necessary to obtain the largest adrenal measurements. The reference intervals of adrenal measurements were inferred from the values obtained in the healthy and chronically sick cats (mean ± 0.96 SD): adrenal length was 8.9-12.5 mm; cranial height was 3.0-4.8 mm; caudal height was 3.0-4.5 mm. The second part of the study consisted of a retrospective analysis of the ultrasonographic examination of the adrenal glands in cats with adrenal diseases (six had hyperaldosteronism and four had pituitary-dependent hyperadrenocorticism) and a descriptive comparison with the reference features obtained in the control groups from the prospective study. Cats with hyperaldosteronism presented with unilateral severely enlarged adrenal glands. However, a normal contralateral gland did not preclude a contralateral infiltration in benign or malignant adrenal neoplasms. The ultrasonographic appearance of the adrenal glands could not differentiate benign and malignant lesions. The ultrasonographic appearance of pituitary-dependent hyperadrenocorticism was mainly a symmetrical adrenal enlargement; however, a substantial number of cases were within the reference intervals of adrenal size. © ISFM and AAFP 2012.

PURPOSE OF REVIEW To describe the significance of a common adrenal radiological finding on computed tomography or MRI. RECENT FINDINGS Bilateral adrenocortical hyperplasia is the common expression of a variety of adrenal disorders, and its cause needs to be properly assessed in order to institute appropriate management. SUMMARY Behind the radiological finding of bilateral adrenal enlargement, there is a spectrum of diseases that require diagnostic evaluation and management. Many cases are benign and not associated with abnormalities of endocrine function. However, these abnormalities may develop years after the initial diagnosis has been made.

We have previously demonstrated that neutral cholesterol ester hydrolase 1 (Nceh1) regulates foam cell formation and atherogenesis through the catalytic activity of cholesterol ester hydrolysis, and that Nceh1 and hormone-sensitive lipase (Lipe) are responsible for the majority of neutral cholesterol ester hydrolase activity in macrophages. There are several cholesterol ester-metabolizing tissues and cells other than macrophages, among which adrenocortical cells are also known to utilize the intracellular cholesterol for steroidogenesis. It has been believed that the mobilization of intracellular cholesterol ester in adrenal glands was facilitated solely by Lipe. We herein demonstrate that Nceh1 is also involved in cholesterol ester hydrolysis in adrenal glands. While Lipe deficiency remarkably reduced the neutral cholesterol ester hydrolase activity in adrenal glands as previously reported, additional inactivation of Nceh1 gene completely abrogated the activity. Adrenal glands were enlarged in proportion to the degree of reduced neutral cholesterol ester hydrolase activity, and the enlargement of adrenal glands and the accumulation of cholesterol esters were most pronounced in the Nceh1/Lipe double-deficient mice. Thus Nceh1 is involved in the adrenal cholesterol metabolism, and the cholesterol ester hydrolytic activity in adrenal glands is associated with the organ enlargement.

Adrenal incidentalomas are a common finding due to the increasing use and improved technology of imaging studies. The majority of these enlargements are non-functional and irreversible. Publications on reversible adrenal enlargement are sparse. Our patient, a 66-year-old man, was admitted to the hospital due to abdominal discomfort. He was treated for rectal carcinoma 3 years before, and was now free of disease. Computed tomography (CT) scan showed no abnormalities other than the incidental finding of bilateral adrenal enlargement. Metastasis was suspected. The CEA-level, however, was within normal range and there was no evidence of hormonal overproduction. After 1 month the patient was reviewed. Physical examination and laboratory testing were normal. Surprisingly, the CT-scan showed a decreased size of both adrenals and after 3 months even showed completely normalized adrenals. Reversible adrenal enlargements are rare. Commonly described causes of adrenal enlargement are haematomas, cystic lesions and infections of the adrenal glands. The patient in this case did not show any clinical, laboratory or radiological signs of any of these diagnoses. The current existing differential diagnosis for bilateral adrenal enlargement is not sufficient to explain the findings in our patient.

The production of an experimental uremia in the albino rat by removal of both kidneys is followed by hypertrophy of the adrenal glands. In the case of male rats 90 days of age this adrenal enlargement amounted to 65 per cent and in the case of female rats 180 days of age 47 per cent. The increase in the size of the whole gland is due entirely to hypertrophy of the cortex. This increase in the volume of cortical tissue amounted to approximately 40 per cent for males and 61 per cent for females and was due in large part to an increase in the size of the cells. The content of water and material soluble in fat solvents was higher in the uremic than the control glands. However after subtraction of such storage materials a true hypertrophy of the cortex still remained. It amounted to 21 per cent. Histologically the stainable fat had a more irregular distribution and was present in lesser amount in the adrenals from the uremic animals. The capillaries of the medulla and reticular cortex were distended. The nuclei of both the cortical and medullary cells were swollen and stained faintly.

We describe three patients with puzzling systemic illnesses in whom computed tomography (CT) led to the diagnosis of active adrenal histoplasmosis. CT was performed in two patients because of gastrointestinal symptoms and weight loss and in the third because of fever developing 2 years after an apparent cure of histoplasmosis. All three patients had adrenal enlargement on CT with features of granulomatous adrenal disease in two. Hormone assays performed after CT supported the diagnosis of adrenal insufficiency and fine-needle adrenal aspiration biopsy with special stains of the aspirates showed histoplasma organisms in all three patients. The combination of adrenal enlargement on CT and laboratory findings of adrenal insufficiency should suggest the diagnosis of histoplasmosis, especially in endemic areas.

Systemic histoplasmosis has various clinical presentations and is of especially concern in immunocompromised patients. A high index of suspicion is required for its diagnosis. A total of 38 cases had been reported from India up to 1996. The most frequent occurrence of cases was around Calcutta in eastern India where the previous case was detected 20 years earlier. However, we have diagnosed 5 cases in the past 2 years from eastern India which are reported here. These cases may indicate under-diagnosis and under-reporting of histoplasmosis in India. All 5 patients had disseminated disease with multisystem involvement including 2 with bilateral adrenal enlargement. Two were diabetic and only 1 patient was infected with HIV.

A case is presented illustrating the diagnostic dilemma of adrenal enlargement following acute pancreatitis.

The sonographic representation of developmental changes occurring in the normal adrenal gland during the first year of life was examined in 84 healthy newborns and infants. As a measure of adrenal size we chose a defined part of standardized adrenal sections, the adrenal size index (ASI). In newborns, ASI was high and decreased during the first year of life. Three different echo types were delineated, each one being predominant in a defined age group. ASI was markedly elevated in 5 patients with the salt-wasting variety of 21-hydroxylase deficiency, whereas in 3 patients without a severe salt loss, ASI was in the upper normal range. Although adrenal enlargement due to salt-wasting 21-hydroxylase deficiency can be recognized by determining ASI, other forms of 21-hydroxylase deficiency do exist in which adrenal enlargement, detectable by ASI measurements, may not be present.

Human infection with Histoplasma capsulatum runs the gamut from asymptomatic to disseminated disease. CT-directed fine-needle aspiration of bilaterally enlarged adrenal glands has been used in diagnosing serious infections with this ubiquitous organism. Three cases have previously been reported in which H. capsulatum infection caused unilateral adrenal enlargement ; this enlargement was diagnosed post-mortem. We describe three patients with unilateral adrenal enlargement due to H. capsulatum whose conditions were diagnosed antemortem. We encourage clinicians to include infection with H. capsulatum as well as other granulomatous diseases and tumors in the differential diagnosis of unilateral adrenal enlargement.

Submitted by Guilherme Lemeszenski (guilherme@nead.unesp.br) on 2013-08-22T18:48:19Z No. of bitstreams: 1 S0100-39842004000300006.pdf: 197396 bytes, checksum: ce665638614f12d9d9ff65585cbc1250 (MD5) Made available in DSpace on 2013-08-22T18:48:19Z (GMT). No. of bitstreams: 1 S0100-39842004000300006.pdf: 197396 bytes, checksum: ce665638614f12d9d9ff65585cbc1250 (MD5) Previous issue date: 2004-06-01 Made available in DSpace on 2013-09-30T19:38:08Z (GMT). No. of bitstreams: 2 S0100-39842004000300006.pdf: 197396 bytes, checksum: ce665638614f12d9d9ff65585cbc1250 (MD5) S0100-39842004000300006.pdf.txt: 19965 bytes, checksum: 2f1a58bc4f13e608166c1b6e52709d14 (MD5) Previous issue date: 2004-06-01 Submitted by Vitor Silverio Rodrigues (vitorsrodrigues@reitoria.unesp.br) on 2014-05-20T15:10:14Z No. of bitstreams: 2 S0100-39842004000300006.pdf: 197396 bytes, checksum: ce665638614f12d9d9ff65585cbc1250 (MD5) S0100-39842004000300006.pdf.txt: 19965 bytes, checksum: 2f1a58bc4f13e608166c1b6e52709d14 (MD5) Made available in DSpace on 2014-05-20T15:10:14Z (GMT). No. of bitstreams: 2 S0100-39842004000300006.pdf: 197396 bytes, checksum: ce665638614f12d9d9ff65585cbc1250 (MD5) S0100-39842004000300006.pdf.txt: 19965 bytes, checksum: 2f1a58bc4f13e608166c1b6e52709d14 (MD5) Previous issue date: 2004-06-01 Neste estudo foram avaliadas, por meio de tomografia computadorizada, as adrenais em indivíduos sem tuberculose (grupo 1 - G1) e com tuberculose (grupo 2 - G2). A dimensão ântero-posterior, a espessura e o comprimento das adrenais foram comparados no G1 e no G2. Foram também avaliadas a duração da doença com a ocorrência de alteração morfológica no G2, e a distribuição segundo o sexo, a idade e a cor da pele no G1 e no G2. Neste estudo houve diferença nas dimensões ântero-posterior e espessura da adrenal direita entre o G1 e o G2. Observou-se maior ocorrência do sexo masculino e de indivíduos de pele branca no G2. Não houve associação entre a duração da doença e a ocorrência de alteração morfológica no G2. Maior ocorrência da alteração morfológica tipo alargamento foi observada no G2. Os principais achados pela tomografia computadorizada, nos pacientes com tuberculose, foram alargamento da adrenal sem calcificação, alargamento da adrenal com calcificação puntiforme e calcificação de aspecto residual da adrenal. We evaluated the adrenals of individuals without tuberculosis (group 1 - G1) and with tuberculosis (group 2 - G2) using computed tomography. The antero-posterior length, the thickness, and the longitudinal length of the adrenals were compared in G1 and G2. The duration of the disease, the occurrence of morphologic abnormalities in G2, the distribution according to sex, age and skin color were also studied. There was difference in the antero-posterior length and thickness of right adrenal between G1 and G2. A higher prevalence of white skin male individuals was observed in G2. There was no association between duration of the disease and the occurrence of morphologic abnormalities in G2. A higher occurrence of adrenal enlargement was observed in G2. The main computed tomography findings in patients with tuberculosis were enlargement of the adrenal without calcification, enlargement of the adrenal with punctiform calcifications, and residual calcification of the adrenal. Unesp Faculdade de Medicina Departamento de Doenças Tropicais e Diagnóstico por Imagem Unesp Faculdade de Medicina Departamento de Doenças Tropicais e Diagnóstico por Imagem

A 14-year-old neutered female cat was presented for the investigation of aggression and male-type behaviour. Bilateral adrenal enlargement together with elevated plasma concentrations of oestradiol and testosterone were identified, with no evidence of hypercortisolaemia. These findings are similar to the syndrome of hyperadrenocorticism recognised most commonly in ferrets. The cat was treated for six months with the enzyme inhibitor drug, trilostane, and showed a moderate improvement in clinical signs.

Human infection with Histoplasma capsulatum is largely asymptomatic but disseminated disease is fatal if left untreated. We report a case of bilateral adrenal enlargement due to disseminated histoplasmosis in a Bangladeshi male who was successfully treated.

ACTH is used in childhood to treat infantile spasms and acute cerebellar encephalopathy (opsoclonus-cerebellar ataxia syndrome). We report two infants with ultrasonographic and CT evidence of massive, reversible adrenal enlargement secondary to exogenous ACTH therapy for these disorders.

Objective.—We describe a case of macronodular hyperplasia with marked adrenal enlargement in which mature adipose tissue was a significant component. To our knowledge, this condition has not been reported previously. Methods.—A 42-year-old woman with newly diagnosed Cushing’s syndrome underwent endoscopic bilateral adrenalectomy to remove bilateral adrenal masses. Results.—Both adrenal glands displayed features of macronodular hyperplasia with marked adrenal enlargement, and abundant mature adipose tissue was identified in some nodules of both glands. Conclusions.—Lipomatous metaplasia is histologically demonstrated in a case of macronodular hyperplasia with marked adrenal enlargement. This distinctive change may be secondary to metaplastic transformation of either stromal cells or adrenocortical cells. The presence of lipomatous metaplasia would appear to indicate adrenocortical process, since, to our knowledge, it has never before been described in the adrenal nodule.

Metastases to the adrenal glands are common in patients with malignancy but malignant disease presenting as Addisonian crisis is rare. The authors presented two patients with acute Addisonian crises due to metastatic infiltration of the adrenal glands. They were otherwise asymptomatic from the primary tumor. Computed tomographic scan showed bilateral adrenal enlargement and transcutaneous biopsy confirmed metastatic adenocarcinoma in the adrenals. Adequate glucocorticoid replacement improves quality of life and prolongs survival.

A 78-year-old man, previously treated for prostate and colorectal cancer, was admitted to the hospital because of persistent fever. He was found to have bilateral large adrenal masses and adrenal insufficiency. Primary large B-cell lymphoma was proven by aspiration biopsy of the left adrenal gland. On presentation, no evidence of lymphoma outside the adrenal glands was found. The patient died before treatment could be initiated. The autopsy report is discussed briefly. Primary adrenal lymphoma is a rare entity and should be considered in a patient with bilateral adrenal masses without nodular involvement.

Adrenal enlargement was followed by serial ultrasonography in an infant with congenital lipoid adrenal hyperplasia (lipoid CAH) from day 12 until 2 years and 4 months of age, when they were no longer detectable. Contrary to other types of CAH in which the configuration changes soon after replacement therapy, this infant with lipoid CAH showed persistent adrenal cortex enlargement due to massive accumulation of lipids and cholesterol resulting in a damaged glandular cyto-architecture. Conclusion ultrasonographically persistent enlargement of the adrenals after replacement therapy is suggestive of the lipoid form of CAH.

To assess the properties of adrenal lesions with and without known primary cancer and investigate predictors for differential diagnosis between benign and malignant adrenal enlargement.This retrospective study used fluorine-18 fludeoxyglucose positron emission tomography (PET)/CT in 325 patients with adrenal lesions (229 with known primary cancer and 96 without primary cancer). Age, sex, the presence of right and left masses, nodules or hyperplasia, unenhanced attenuation, maximum standardised uptake value (SUVmax) ratio, and the presence of metastasis in other body parts and locations of the primary cancer were assessed. Univariate and multivariate analyses were used to assess variables associated with risk of adrenal metastasis.Patients with adrenal metastasis vs those without had a higher frequency of primary lung cancer (52.3% vs 30.7%) but a lower frequency of gastrointestinal cancer (7.9% vs 16.6%). The frequency of other abnormalities, including adenoma and hyperplasia, was similar between patients with and without known primary cancer. A higher proportion of patients with adrenal metastasis regardless of primary cancer site were younger, had a nodule or a mass, had an unenhanced attenuation of10 HU, had an SUVmax ratio of2.5, and had metastasis in other body parts. Analysis found independent associations of age, unenhanced attenuation of10 HU, SUVmax ratio of2.5 and the presence of metastasis in other body parts with adrenal metastasis. The combination of the four variables was strongly associated with adrenal metastasis.PET/CT was useful in characterising adrenal lesions as benign or malignant and helpful in identifying adrenal metastasis and cancer severity.PET/CT can help in the differential diagnosis between benign and malignant adrenal enlargement.

To study the morphology of the adrenal glands of patients with Addison's disease an ultrasound and a computed tomographic scan of the adrenal glands were performed in 28 patients with Addison's disease. Thirteen patients had bilateral, asymmetric adrenal enlargement. In six of these patients, areas of necrosis and calcification were also seen. Six patients had atrophic glands with calcification and nine patients had normal/atrophic glands without calcification. After instituting appropriate treatment, computed tomography (CT) was repeated between 6 months and 3 years later in 10 of the 13 patients with adrenal enlargement. A reduction in gland size was noted in all patients and one had functional recovery. We conclude that the appearance of the adrenal glands on CT depends not only on the nature of the underlying disease but also on the duration of the illness and the type of treatment.