Objective: To summarize the existing knowledge about adrenal gland abscesses, including etiology, clinical presentation, common laboratory and imaging findings, management and overall morbidity and mortality. Design: Systematic literature review. Methods: We performed a search in the PubMed database using search terms: ‘abscess and adrenal glands’, ‘adrenalitis’, ‘infection and adrenal gland’, ‘adrenal abscess’, ‘adrenal infection’ and ‘infectious adrenalitis’. Articles from 2017 to 2022 were included. We found total of 116 articles, and after applying exclusion criteria, data from 73 articles was included in the final statistical analysis. Results: Of 84 patients included in this review, 68 were male (81%), with a mean age of 55 years (range: 29 to 85 years). Weight loss was the most frequent symptom reported in 58.3% patients, followed by fever in 49%. Mean duration of symptoms was 4.5 months. The most common laboratory findings were low cortisol (51.9%), elevated ACTH (43.2%), hyponatremia (88.2%) and anemia (83.3%). Adrenal cultures were positive in 86.4% cases, with Histoplasma capsulatum (37.3%) being the leading causative agent. Blood cultures were positive in 30% of patients. The majority of the adrenal infections occurred through secondary dissemination from other infectious foci and abscesses were more commonly bilateral (70%). A total of 46.4% of patients developed long-term adrenal insufficiency requiring treatment. Abscess drainage was performed in 7 patients (8.3%) and adrenalectomy was performed in 18 (21.4%) patients. The survival rate was 92.9%. Multivariate analysis showed that the only independent risk factor for mortality was thrombocytopenia (p = 0.048). Conclusion: Our review shows that adrenal abscesses are usually caused by fungal pathogens, and among these, Histoplasma capsulatum is the most common. The adrenal glands are usually involved in a bilateral fashion and become infected through dissemination from other primary sources of infection. Long-term adrenal insufficiency develops in 46% of patients, which is more common than what is observed in non-infectious etiology of adrenal gland disorders. Mortality is about 7%, and the presence of thrombocytopenia is associated with worse prognosis. Further prospective studies are needed to better characterize optimal testing and treatment duration in patients with this relatively rare but challenging disorder.

Introduction: Acute pancreatitis is one of the leading causes of GI-related hospitalizations in the USA. Around 20% of these cases are characterized as severe, leading to complications including necrotizing pancreatitis. 1 Enterococci are the most-commonly isolated species in infected pancreatic necrosis followed by Escherichia coli, with anaerobic bacteria being more rarely involved. 2 We present a rare case of acute necrotizing pancreatitis infected with Prevotella species in a young patient. Case Description/Methods: 28-year-old man with ADHD and hypertension presented with acute epigastric pain radiating to the left. He was found to have a lipase level of 3897U/L, a triglyceride level of 2716mg/dL, in addition to acute interstitial pancreatitis with extensive peri-pancreatic inflammation on CT scan. He was admitted for pain control, IV fluids and insulin. During his stay, he also received plasma exchange for the treatment of hypertriglyceridemia and was discharged upon improvement of symptoms. He represented with abdominal pain and was found to have pancreatic walled-off necrosis with gas concerning for superimposed infection with gastric outlet and colonic obstruction (Figure). A percutaneous drain was placed; his course was complicated by sepsis and broad spectrum antibiotics were initiated. Drain fluid cultures grew moderate Staphylococcus aureus and Streptococcus intermedius, heavy Prevotella buccae, Prevotella denticola and Fusobacterium. Hospital course was further complicated by worsening abdominal pain and distention. Repeat CT revealed increasing colonic and small bowel dilatation due to stricture in descending colon. Gastroview enema demonstrated probable fistula tract. He underwent percutaneous endoscopic gastrostomy tube placement and creation of a loop transverse colostomy. Post-operatively, patient was transitioned to oral antibiotics for additional four weeks with outpatient follow-up. Discussion: Acute necrotizing pancreatitis, especially if infected, is associated with poor outcomes. We highlight a rare case of hypertriglyceridemia-induced pancreatitis complicated by necrotizing infection with heavy Prevotella species. We demonstrate the importance of early suspicion of complicated acute pancreatitis and the need for early intervention to prevent hospital re-admission and improve the morbidity and mortality associated with infected pancreatic necrosis.[1899] Figure 1. A. Initial CT showing necrotizing pancreatitis with large evolving peri-pancreatic walled off necrosis. B. Follow up CT showing large evolving peri-pancreatic walled off necrosis with evidence of new gas locules within the collection.

Acute pancreatitis is one of the leading causes of gastrointestinal-related hospitalizations in the United States. One of the complications of acute pancreatitis is infected pancreatic necrosis. We present a rare case of acute necrotizing pancreatitis infected with Prevotella species in a young patient. We demonstrate the importance of early suspicion of complicated acute pancreatitis and the need for early intervention to prevent hospital re-admission and improve the morbidity and mortality associated with infected pancreatic necrosis.

Purpose of review Hypertriglyceridemia-induced acute pancreatitis (HTG-AP) should be considered in all cases of acute pancreatitis and triglyceride levels measured early, so that appropriate early and long-term treatment can be initiated. Recent findings In most cases of HTG-AP, conservative management (nothing by mouth, intravenous fluid resuscitation and analgesia) is sufficient to achieve triglyceride levels less than 500 mg/dl. Intravenous insulin and plasmapheresis are sometimes used, although prospective studies showing clinical benefits are lacking. Pharmacological management of hypertriglyceridemia (HTG) should start early and target triglyceride levels of less than 500 mg/dl to reduce the risk or recurrent acute pancreatitis. In addition to currently used fenofibrate and omega-3 fatty acids, several novel agents are being studied for long-term treatment of HTG. These emerging therapies focus mainly on modifying the action of lipoprotein lipase (LPL) through inhibition of apolipoprotein CIII and angiopoietin-like protein 3. Dietary modifications and avoidance of secondary factors that worsen triglyceride levels should also be pursued. In some cases of HTG-AP, genetic testing may help personalize management and improve outcomes. Summary Patients with HTG-AP require acute and long-term management of HTG with the goal of reducing and maintaining triglyceride levels to less than 500 mg/dl.