1990, The British Journal of Radiology, 63, 137-138 Case reports ROESLER, P. J. & WILLS, J. S., 1986. Hepatic actinomycosis: CT
features. Journal of Computer Assisted Tomography, 335-337.
10(2),
SHAH, H. R., WILLIAMSON, M. R., BOYD, C. M., BALACHARDRAN, S., ANGTUACO, T. L. & MCCONNELL, J. R.,
1987. CT findings in abdominal actinomycosis. Journal of Computer Assisted Tomography, 11(3), 466-469.
SURUR, F., 1974. Actinomycosis of female genital tract. New York State Journal of Medicine, 74, 408-410. WEESE, W. C. & SMITH, I. M., 1975. A study of 57 cases of
actinomycosis over a 30 year period. A diagnostic 'failure' with good prognosis after treatment. Archives of Internal Medicine, 135, 1562-1568.
Unusual appearances of an adrenal mass on computed tomography By David Hughes, MRCP, FRCR and Stephen Golding, DMRD, FRCR Oxford Regional Computed Tomography Unit, Churchill Hospital, Headington, Oxford {Received June 1989)
When patients undergo imaging investigations to stage malignant disease the finding of a mass in the adrenal gland may not necessarily represent metastasis. Incidental non-functioning adrenal masses have been reported in 0.6% of examinations of the abdomen by computed tomography (CT) (Glazer et al, 1982). We report a patient with such a finding, whose CT scans showed unusual appearances. Case report A 64-year-old Caucasian man with histologically proven adenocarcinoma of the prostate was referred for CT for staging purposes. There were no clinical signs to suggest spread of the disease and no symptoms referable to the abdomen. Prior to this he had been well. Computed tomography showed moderate enlargement of the prostate with no evidence of periprostatic infiltration or lymphadenopathy. The left adrenal gland was replaced by a large, well circumscribed mass measuring 8 x 9 x l 0 c m . The mass was of uniformly high attenuation (83 Hounsfield Units, standard deviation 4.3) apart from a few flecks of overt calcification within it (Fig. 1). Sections taken following an intravenous injection of 100 ml of meglumine diatrizoate 65% (Urografin 310M, Schering) showed no detectable increase in attenuation, indicating that the "mass" was avascular. A normal right adrenal gland was identified. He was normotensive and a chest radiograph was normal. Serum biochemistry showed no abnormality and there was no elevation of urinary vanillylmandelic acid level. At CT-guided biopsy, two passes with a Trucut biopsy needle failed to obtain any material. A 14G intravenous cannula (Abbocath, Abbott) was therefore inserted and aspiration revealed pus, 40 ml of which was removed. Cytological examination of this showed necrotic debris and dystrophic calcification. Bacteriological examination showed no pus cells or organisms, including acid fast bacilli. On culture there was a mild growth of staphylococcus epidermis, believed to be a contaminant. Cultures for tuberculosis were negative at 6 weeks, but a tuberculin test was strongly positive at a dilution of 1 in 10,000. A presumptive diagnosis of tuberculous abscess was made and he was started on antituberculous therapy. He underwent a radical course of radiotherapy to the pelvis and remains well 7 months later.
Vol. 63, No. 746
Discussion
To our knowledge, an adrenal mass with these appearances has not been previously reported. Incidental adrenal masses may show evidence of calcification on radiographs, ultrasound or CT in 30% of patients (Kenney & Stanley, 1987). The appearances in our patient were unusual in that although there were tiny flecks of calcification, the mass was otherwise of uniformly high attenuation owing to calcium deposition in chronic suppuration. A previously reported case of unilateral caseous tuberculosis contained no calcification, was of low attenuation and demonstrated ring enhancement (Hauser et al, 1981). None of these features were present in our patient. Organisms that infect the adrenal glands in adults include tuberculosis, histoplasmosis and blastomycosis as well as pyogenic infections (O'Brien et al, 1987). Granulomatous inflammation usually causes bilateral adrenal gland enlargement, with subsequent atrophy
Figure 1. Enhanced CT section of the upper abdomen, showing the left adrenal gland replaced by a well defined mass of high attenuation, containing small areas of calcification (arrows). (W = 300, L = 38.)
137
1990, The British Journal of Radiology, 63, 138-140
leading to bilateral small calcified glands and sometimes Addison's disease (Wilms et al, 1983). Unilateral disease appears to be uncommon. The finding of a unilateral adrenal mass in a patient with known malignant disease must always raise the possibility of metastasis. We agree with Bernadino et al (1985) that guided biopsy is indicated in these circumstances, if only to exclude metastasis, as in our patient. Acknowledgments We are grateful to Dr C. J. Alcock for his permission to publish clinical details of this patient and to Miss J. Edmonds and Mr S. Ashington for their assistance.
References BERNADINO, GRAHAM,
Case reports MCCLEES, K.,
BAUMGARTNER, B.
R.,
TORRES, W.
E.
GLAZER, H. S., WEGMAN, P. J., SAGEL, S., LEVITT, R. G.
WALTHER, M. M., PHILLIPS, V. M., WHITAKER SEWELL, C , GEDGAUDAS-
&
MCCLENNAN, B. L., 1982. Non-functioning adrenal masses: incidental discovery on computed tomography. American Journal of Roentgenology, 139, 81-85. HAUSER, H., BOTTIKHA, J. G. & WETTSTEIN, P., 1981. Pathology
of the adrenal glands: common and uncommon findings in CT. European Journal of Radiology, 1, 215-226. KENNEY, P. J. & STANLEY, R. J., 1987. Calcified adrenal masses. Urologic Radiology, 9, 9-15. O'BRIEN, W. M., CHOYKE, P. L., COPELAND, J., KLAPPENBACH,
R. S. & LYNCH, J. H., 1987. Computed tomography of adrenal abscess. Journal of Computer Assisted Tomography, 11 (3), 550-551. WILMS, G. E., BAERT, A. L., KINT, E. J., PRINGTO, J. H.
M. E., S. D.,
&
ERWIN, B. C , 1985. CT guided adrenal biopsy: accuracy, safety and indications. American Journal of Roentgenology, 144, 67-69.
&
GODDEERIS, P. G., 1983. Computed tomographic findings in bilateral adrenal tuberculosis. Radiology, 146, 729-730.
Magnetic resonance imaging of the chest in infectious mononucleosis By P. Goddard, MD, FRCR, D. Kinsella, FRCR, *A. W. Duncan, FRCR, *A. Hamilton, MRCP and *F. Carswell, MRCP Bristol Royal Infirmary and *Bristol Royal Hospital for Sick Children, Bristol (Received June 1989 and in revised form August 1989)
Infectious mononucleosis is a disease of young adults, typically presenting with malaise, fever, sore throat and cervical adenopathy (Juel-Jensen, 1983). Non-specific respiratory symptoms may also be present. The diagnosis is confirmed by serological tests for the virus. A case is reported in which the presence of lymphadenopathy as demonstrated by a magnetic resonance imaging (MRI) scan led to the diagnosis of infectious mononucleosis. Case report A 12-year-old patient with a 6-year history of asthma (controlled by becotide and ventolin inhalers (Allen and Hanburys)) complained of lethargy and poor appetite following a recent chest infection. On examination, the only abnormality was an enlarged left cervical node. The chest radiograph (Fig. 1) was normal. As part of a study of pulmonary disease in childhood, an MRI scan was arranged. The chest was imaged in the coronal plane with T,-weighted spin-echo (time to repeat (TR) 500 ms, time to echo (TE) 26 ms) and short tau inversion recovery (STIR) (TR 1500 ms T, 100 ms) pulse sequences. This showed intra- and extra-thoracic lymphadenopathy (Figs 2, 3). The former is seen in the subcarinal and broncho-pulmonary regions; the extra-thoracic lymphadenopathy is present in the left axilla and left supra-clavicular regions. No lung parenchymal abnormality was demonstrated. The appearances were considered likely to be a result of infectious mononucleosis, lymphoma or sarcoidosis. Other possibilities included "cat-scratch fever" and brucellosis. The
138
Figure 1. Normal chest radiograph. There is no evidence of hilar adenopathy. The British Journal of Radiology, February 1990
features. Journal of Computer Assisted Tomography, 335-337.
10(2),
SHAH, H. R., WILLIAMSON, M. R., BOYD, C. M., BALACHARDRAN, S., ANGTUACO, T. L. & MCCONNELL, J. R.,
1987. CT findings in abdominal actinomycosis. Journal of Computer Assisted Tomography, 11(3), 466-469.
SURUR, F., 1974. Actinomycosis of female genital tract. New York State Journal of Medicine, 74, 408-410. WEESE, W. C. & SMITH, I. M., 1975. A study of 57 cases of
actinomycosis over a 30 year period. A diagnostic 'failure' with good prognosis after treatment. Archives of Internal Medicine, 135, 1562-1568.
Unusual appearances of an adrenal mass on computed tomography By David Hughes, MRCP, FRCR and Stephen Golding, DMRD, FRCR Oxford Regional Computed Tomography Unit, Churchill Hospital, Headington, Oxford {Received June 1989)
When patients undergo imaging investigations to stage malignant disease the finding of a mass in the adrenal gland may not necessarily represent metastasis. Incidental non-functioning adrenal masses have been reported in 0.6% of examinations of the abdomen by computed tomography (CT) (Glazer et al, 1982). We report a patient with such a finding, whose CT scans showed unusual appearances. Case report A 64-year-old Caucasian man with histologically proven adenocarcinoma of the prostate was referred for CT for staging purposes. There were no clinical signs to suggest spread of the disease and no symptoms referable to the abdomen. Prior to this he had been well. Computed tomography showed moderate enlargement of the prostate with no evidence of periprostatic infiltration or lymphadenopathy. The left adrenal gland was replaced by a large, well circumscribed mass measuring 8 x 9 x l 0 c m . The mass was of uniformly high attenuation (83 Hounsfield Units, standard deviation 4.3) apart from a few flecks of overt calcification within it (Fig. 1). Sections taken following an intravenous injection of 100 ml of meglumine diatrizoate 65% (Urografin 310M, Schering) showed no detectable increase in attenuation, indicating that the "mass" was avascular. A normal right adrenal gland was identified. He was normotensive and a chest radiograph was normal. Serum biochemistry showed no abnormality and there was no elevation of urinary vanillylmandelic acid level. At CT-guided biopsy, two passes with a Trucut biopsy needle failed to obtain any material. A 14G intravenous cannula (Abbocath, Abbott) was therefore inserted and aspiration revealed pus, 40 ml of which was removed. Cytological examination of this showed necrotic debris and dystrophic calcification. Bacteriological examination showed no pus cells or organisms, including acid fast bacilli. On culture there was a mild growth of staphylococcus epidermis, believed to be a contaminant. Cultures for tuberculosis were negative at 6 weeks, but a tuberculin test was strongly positive at a dilution of 1 in 10,000. A presumptive diagnosis of tuberculous abscess was made and he was started on antituberculous therapy. He underwent a radical course of radiotherapy to the pelvis and remains well 7 months later.
Vol. 63, No. 746
Discussion
To our knowledge, an adrenal mass with these appearances has not been previously reported. Incidental adrenal masses may show evidence of calcification on radiographs, ultrasound or CT in 30% of patients (Kenney & Stanley, 1987). The appearances in our patient were unusual in that although there were tiny flecks of calcification, the mass was otherwise of uniformly high attenuation owing to calcium deposition in chronic suppuration. A previously reported case of unilateral caseous tuberculosis contained no calcification, was of low attenuation and demonstrated ring enhancement (Hauser et al, 1981). None of these features were present in our patient. Organisms that infect the adrenal glands in adults include tuberculosis, histoplasmosis and blastomycosis as well as pyogenic infections (O'Brien et al, 1987). Granulomatous inflammation usually causes bilateral adrenal gland enlargement, with subsequent atrophy
Figure 1. Enhanced CT section of the upper abdomen, showing the left adrenal gland replaced by a well defined mass of high attenuation, containing small areas of calcification (arrows). (W = 300, L = 38.)
137
1990, The British Journal of Radiology, 63, 138-140
leading to bilateral small calcified glands and sometimes Addison's disease (Wilms et al, 1983). Unilateral disease appears to be uncommon. The finding of a unilateral adrenal mass in a patient with known malignant disease must always raise the possibility of metastasis. We agree with Bernadino et al (1985) that guided biopsy is indicated in these circumstances, if only to exclude metastasis, as in our patient. Acknowledgments We are grateful to Dr C. J. Alcock for his permission to publish clinical details of this patient and to Miss J. Edmonds and Mr S. Ashington for their assistance.
References BERNADINO, GRAHAM,
Case reports MCCLEES, K.,
BAUMGARTNER, B.
R.,
TORRES, W.
E.
GLAZER, H. S., WEGMAN, P. J., SAGEL, S., LEVITT, R. G.
WALTHER, M. M., PHILLIPS, V. M., WHITAKER SEWELL, C , GEDGAUDAS-
&
MCCLENNAN, B. L., 1982. Non-functioning adrenal masses: incidental discovery on computed tomography. American Journal of Roentgenology, 139, 81-85. HAUSER, H., BOTTIKHA, J. G. & WETTSTEIN, P., 1981. Pathology
of the adrenal glands: common and uncommon findings in CT. European Journal of Radiology, 1, 215-226. KENNEY, P. J. & STANLEY, R. J., 1987. Calcified adrenal masses. Urologic Radiology, 9, 9-15. O'BRIEN, W. M., CHOYKE, P. L., COPELAND, J., KLAPPENBACH,
R. S. & LYNCH, J. H., 1987. Computed tomography of adrenal abscess. Journal of Computer Assisted Tomography, 11 (3), 550-551. WILMS, G. E., BAERT, A. L., KINT, E. J., PRINGTO, J. H.
M. E., S. D.,
&
ERWIN, B. C , 1985. CT guided adrenal biopsy: accuracy, safety and indications. American Journal of Roentgenology, 144, 67-69.
&
GODDEERIS, P. G., 1983. Computed tomographic findings in bilateral adrenal tuberculosis. Radiology, 146, 729-730.
Magnetic resonance imaging of the chest in infectious mononucleosis By P. Goddard, MD, FRCR, D. Kinsella, FRCR, *A. W. Duncan, FRCR, *A. Hamilton, MRCP and *F. Carswell, MRCP Bristol Royal Infirmary and *Bristol Royal Hospital for Sick Children, Bristol (Received June 1989 and in revised form August 1989)
Infectious mononucleosis is a disease of young adults, typically presenting with malaise, fever, sore throat and cervical adenopathy (Juel-Jensen, 1983). Non-specific respiratory symptoms may also be present. The diagnosis is confirmed by serological tests for the virus. A case is reported in which the presence of lymphadenopathy as demonstrated by a magnetic resonance imaging (MRI) scan led to the diagnosis of infectious mononucleosis. Case report A 12-year-old patient with a 6-year history of asthma (controlled by becotide and ventolin inhalers (Allen and Hanburys)) complained of lethargy and poor appetite following a recent chest infection. On examination, the only abnormality was an enlarged left cervical node. The chest radiograph (Fig. 1) was normal. As part of a study of pulmonary disease in childhood, an MRI scan was arranged. The chest was imaged in the coronal plane with T,-weighted spin-echo (time to repeat (TR) 500 ms, time to echo (TE) 26 ms) and short tau inversion recovery (STIR) (TR 1500 ms T, 100 ms) pulse sequences. This showed intra- and extra-thoracic lymphadenopathy (Figs 2, 3). The former is seen in the subcarinal and broncho-pulmonary regions; the extra-thoracic lymphadenopathy is present in the left axilla and left supra-clavicular regions. No lung parenchymal abnormality was demonstrated. The appearances were considered likely to be a result of infectious mononucleosis, lymphoma or sarcoidosis. Other possibilities included "cat-scratch fever" and brucellosis. The
138
Figure 1. Normal chest radiograph. There is no evidence of hilar adenopathy. The British Journal of Radiology, February 1990
