Case Lovely adrenal glands

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1 Case Lovely adrenal glands Hidayatullah Hamidi, Ahmad Reshad Faizi, Sahar Maroof, Mer Mahmood Shah hoshang, Nawaz nasery, Farhad Farzam, Mohibullah Salehzai, Jamshid Sadiqi French medical institute for children, Kabul, Afghanistan French medical institute for children, Kabul, Afghanistan Section: Paediatric Radiology Published: 2016, Feb. 19 Patient: 1 day(s), female Clinical History Healthy neonate was sent for checkup ultrasound. Imaging Findings Figure 1: A well circumscribed, solid appearing, inverted Y shaped structure over the right kidney beneath the liver. Hypoechoic, peripheral cortex and the hyperechoic central medulla are well differentiated. There is no evidence of any cystic area, abnormal lobulation of focal abnormal area (Figure 1a). The length of one limb is 15 mm and its thickness is 5 mm (Figure 1b). Figure 2a: A well circumscribed, solid appearing C or V shaped structure over the left kidney encasing the upper pole cortex of left kidney. Smooth margins and well differentiated adrenal cortex and medulla are noted (Figure 2a). The length of one limb is 14 mm and its thickness is 5 mm (Figure 2b). These high resolution, typical ultrasound images are so lovely that radiologist's eyes enjoy seeing them. Discussion Adrenal glands are retroperitoneal organs located in the perirenal spaces. [1] The right adrenal

2 gland is located posterior to the inferior vena cava and superomedial to right renal upper pole and the left one is located somewhat lower and more anterior relative to left kidney. [2] The configuration of adrenal glands is described as pyramidal, V" shaped, Y" shaped, [1] triangle, inverted Y"shape [3] or as arrow head [4]. If the ipsilateral kidney has not developed, the adrenal gland can have a discoid appearance. [2] The adrenal gland has a body and two limbs. [4] The limbs have a concave or straight border in older children, but may be convex with a bulbous tip early in life. [5] The normal adrenal glands are relatively large and easy to see in the neonates, [6] but their size may decrease by fifty percent between 1 and 3 weeks of life [3]. They have thick, uniform, hypoechoic, peripherally located cortex and central, relatively thin and echogenic medulla. [7] With increasing age, cortex becomes smaller and the medulla relatively larger. [7, 8] Due to the relatively larger size and less amount of retroperitoneal fat, ultrasound with high frequency probe can provide high-resolution images of normal neonatal adrenals. [1, 7] In a prospective study for adrenal gland visualization on real-time ultrasound over 92 neonates, the right gland was identified in 97% and the left in 83% of neonates. [7] Various sonographic measurements are described to evaluate adrenal size. [3] These measurements are used to support some clinically suspected pathologic processes like congenital adrenal hyperplasia. The length of normal neonatal adrenal gland is between 0.9 and 3.6 cm (mean 1.5 to 1.7 cm) and its thickness ranges between 0.2 and 0.5 cm (mean 0.3cm). [9] Final Diagnosis Normal neonatal adrenal glands Differential Diagnosis List congenital adrenal hyperplasia, Adrenal gland hemorrhage Figures Figure 1 Right adrenal gland

3 Right adrenal gland beneath the liver and over the upper pole of right kidney. Well differentiation between hypoechoic cortex and echogenic medulla. Normal sized right adrenal gland: The length of one limb is 15 mm and the thickness is 5 mm. Another view of the lovely adrenal Figure 2 Left side adrenal gland

4 Left adrenal gland encasing the upper pole cortex of left kidney. Smooth margins and well differentiated adrenal cortex and medulla are noted. Normal sized left adrenal gland: The length of the one limb is 14 mm and the transverse diameter is 5 mm. References [1] Paterson, Anne (2002) Adrenal pathology in childhood: a spectrum of disease European radiology 12.10: [2] Westra, Sjirk J., et al (1994) Imaging of the adrenal gland in children Radiographics 14.6:

5 [3] Sivit, C. J., et al (1991) Sonography in neonatal congenital adrenal hyperplasia American journal of roentgenology 156.1: [4] Adam, Andy, et al. (2014) Grainger & Allison's Diagnostic Radiology. Elsevier Health Sciences [5] Mahboubi 5, Patel K, O'Neill JA (1988) Computed tomography in the evaluation of adrenal glands in infants and children J Comput Tomogr 12: [6] Chambrier, Evelyne Diane, Claudine Heinrichs, and Fred E. Avni (2002) Sonographic appearance of congenital adrenal hyperplasia in utero Journal of ultrasound in medicine 21.1: [7] Oppenheimer DA, Carroll BA, Yousem S (1983) Sonography of the normal neonatal adrenal gland Radiology 146: [8] Kangarloo, Hooshang, et al (1986) Sonography of adrenal glands in neonates and children: changes in appearance with age Journal of clinical ultrasound 14.1: [9] Siegel, Marilyn J., ed (2011) Pediatric sonography Lippincott Williams & Wilkins Citation Hidayatullah Hamidi, Ahmad Reshad Faizi, Sahar Maroof, Mer Mahmood Shah hoshang, Nawaz nasery, Farhad Farzam, Mohibullah Salehzai, Jamshid Sadiqi French medical institute for children, Kabul, Afghanistan hedayatullah.hamidi@gmail.com (2016, Feb. 19) Lovely adrenal glands {Online} URL: