Giant Bilateral Adrenal Myelolipoma

A 36-year-old Hispanic female diagnosed with non-classical congenital adrenal hyperplasia and salt wasting disorder on chronic exogenous steroids presented to our emergency department with excruciating bilateral flank pain, 10/10 in intensity, associated with nausea, vomiting, and generalised weakness. On examination, the patient was in hypovolemic shock with BP of 65/45 mmHg, MAP 52 mmhg, and HR 110 b/min. She was resuscitated with intravenous fluids and intravenous corticosteroids. Physical examination was otherwise unremarkable. Haematology and serum chemistry were noncontributory. The patient had been on high dosages of narcotic analgesics due to persistent abdominal pain, which infrequently required hospitalisations. Current and serial contrast computed tomography scans over the past few years revealed progressive growth of the tumour (Figure 1) with concomitant increase in the level of hormones. The 17 hyroxyprogesterone level was 8000 nmol/lit, androstenedione 864 ng/dL, and total testosterone 65 ng/dL. The surgery and endocrinology teams were consulted, and the patient underwent bilateral adrenalectomy. Surgery seemed to be the best option to lessen the risk of malignancy, prevent retroperitoneal haemorrhage, alleviate the pain symptoms, and decrease opiod dependence. Gross morphology and histopathology results confirmed the diagnosis of giant adrenal myelolipoma (Figure 2, 3). The postoperative period was uneventful, and the patient was discharged from the hospital. Written informed consent was taken from the patient. Adrenal myelolipomas are rare, benign, and biochemically inactive tumours often diagnosed inadvertently when radiological investigations are performed for other medical conditions. They were first described in 1905 by Gierke as a mass lesion 1Department of Medicine, Maimonides Medical Center, New York, USA 2Department of Pulmonary and Critical Care Medicine, Maimonides Medical Center, New York, USA Sushilkumar Satish Gupta1, Yizhak Kupfer2