Incidental Adrenal Cyst Discovered on Evaluation after High Elevation Fall from a Tree

Presentation Number: SAT 369
Date of Presentation: April 1st, 2017

Shailesh Baral*1, Wonil Tae2, Rama Poola3, Carmel Maria Fratianni1 and Michael G Jakoby IV3
1Southern Illinois University School of Medicine, Springfield, IL, 2OSF Saint Anthony's Health Center, Alton, IL, 3SIU School of Medicine, Springfield, IL

Abstract

Background : Adrenal cysts are rare, with a prevalence no higher than 0.2% in autopsy series and accounting for approximately 1% of incidentally discovered adrenal masses. There have been only about 600 cases reported in the peer reviewed literature. We present a case of an incidental adrenal cyst found during evaluation for trauma after high elevation fall from a tree.

Case: A 34 year old male with history of hypertension diagnosed four years before presentation was brought to the emergency department after falling approximately 12 feet from his deer stand to the ground, sustaining a fracture of the left posterior acetabulum. Computed tomography (CT) of the abdomen revealed a 10 cm right adrenal cyst with peripheral calcifications but no septations, hemorrhage, or solid component. Blood pressure (BP, 197/121 mm Hg) and heart rate (HR, 110-120 bpm) were significantly elevated, and the patient reported he had stopped BP lowering medications approximately three years before admission. The magnitude of BP and HR elevations raised concern for a cystic pheochromocytoma, though plasma free metanephrines drawn while the patient was still in the emergency room were unremarkable. Morning cortisol suppressed to < 1.8 mg/dL on an overnight dexamethasone suppression test. Echinococcal serologies were obtained due to a military deployment to Iraq, with no significant titer of Echinococcus IgG antibody detected. Hypertension and tachycardia were controlled with diltiazem and prazosin, and the patient did well after open reduction and internal fixation of his fracture. Unfortunately, he did not come to endocrinology clinic after hospital discharge.

Conclusions. Historically, adrenal cysts have presented with abdominal pain and a palpable flank mass, though a large number are now discovered incidentally on abdominal imaging studies. They are generally classified into four major histopathological types: endothelial, pseudocyst, epithelial, and parasitic. Endothelial cysts and pseudocysts are most common, though the distinction may be insignificant as both appear to be variants of vascular cysts. In most series, a small number (≤ 5%) of cysts are associated with pheochromocytomas or adrenocortical carcinomas. Surgery is recommended for symptomatic patients, cysts > 5 cm, functional lesions, hemorrhagic cysts, cysts with evidence of mass effect, or suspected carcinoma. Adrenalectomy is preferred by most authors, though in some case series laparoscopic aspirations and gland sparing surgeries have been performed. Asymptomatic patients with cysts < 5 cm and no evidence of hormonal secretion or carcinoma can be followed prospectively with abdominal CT imaging, though there is no consensus on the timing and duration of surveillance due to the low incidence of cases. Surgery was indicated for our patient due to the size of his cyst, though he was unfortunately lost to follow up.

 

Nothing to Disclose: SB, WT, RP, CMF, MGJ IV