No abstract

A 42-year-old man was brought into the Accident and Emergency Department with epigastric discomfort and severe bradycardia. Computerized tomography of the chest revealed spontaneous rupture of the left hemidiaphragm with herniation of small bowel loops.

Objective: To describe a case of hypertensive emergency following embolization of a large myelolipoma.Methods: Using the case report format to present clinical, laboratory, imaging, and dynamic testing data supporting clinical decision making. This is accompanied by a literature review.Results: A 40-year-old male with a history of hypertension presented with acute right upper abdominal pain and shortness of breath. Imaging completed at the transferring facility revealed a large right adrenal mass encapsulating the inferior vena cava. The blood hemoglobin was 7.8 g/dL because of internal hemorrhage into the mass. He underwent embolization of arterial flow to the right adrenal mass. A hypertensive emergency developed, and endocrinology was consulted to evaluate for pheochromocytoma. The plasma and urine normetanephrine were elevated, but the corresponding metanephrines remained normal. Surgery was imminent, and a clonidine suppression test in the surgical intensive care unit resulted in 60% suppression of plasma norepinephrine concentrations. He was cleared for surgery. The pathologic findings confirmed giant myelolipoma with internal hemorrhage.Conclusion: A giant myelolipoma with compressive effects can mimic a pheochromocytoma.

Culture of the aspirate of all patients was felt to be a waste of time and money. Nearly 40% of cases were thought to be idiopathic and settled conservatively without intervention.