Adrenal Abscess in a Neonate Due to Gas-forming Organisms: A Diagnostic Dilemma

Abstract

A case of adrenal abscess due to bacteroides and peptostreptococcus in a 16-day-old infant is presented. The clinical manifestations consisted of a huge abdominal swelling associated with fever and lethargy. This is the first case report of an adrenal abscess due to gas-forming organisms, a finding which makes the preoperative diagnosis more difficult. Surgical drainage, subtotal excision of the abscess wall under cover of antibiotics and preservation of the ipsilateral kidney were followed by survival.

Neonatal Adrenal Abscesses

“…focus remains unknown [5,7], In our cases bacterial examination of abscess material revealed E. coli (case 1) and S. aureus (case 2), but Streptococcus, Bacteroides, Echovirus and herpes simplex could also be isolated [1,2,5,7,15,16].…”

“…The early and accurate diag nosis of an adrenal abscess in neonates is very important to insure appropriate clinical management and surgical treatment. Delayed diagnosis very often results in lethal outcume, particularly in septic neonates or in extension of the seeding of a neonatal adrenal hemorrhage with subse quent abscess formation [1,3], In some reported cases the etiology remains unclear as it was in ours [7,10]. Most likely, adrenal abcesses begin with adrenal hemorrhage, which is a relatively common and well-documented event [11][12][13] frequently associated with traumatic or difficult delivery, hypoxia, sepsis, coagulopathy and macrosomia with maternal diabetes [1,3,6],…”

Focal Bacterial Infections

“…The same laterality and sex predominance are seen with adrenal hemorrhage in the newborn [147,[150][151][152], and it has been postulated that formation of an adrenal abscess requires a preexisting hematoma as a nidus for bacterial seeding [137,138]. This theory of pathogenesis is supported further by clinical observations [134,135,139,146,147] and by objective evidence (e.g., curvilinear calcifications [130,132] documenting the presence of hemorrhage before development of an abscess [134,138,142,145,150].…”

“…The spectrum of organisms responsible for adrenal abscesses is the same as that seen in neonatal sepsis and includes E. coli (seven cases) [17,129,130,[135][136][137][138], group B streptococci (GBS) (four cases) [138][139][140][141], Proteus mirabilis (three cases) [131,132,144], S. aureus [142,143], Bacteroides species [133,145], and two cases each of Streptococcus pneumoniae with Bacteroides species [134]; Peptostreptococcus species [146] was recovered from one case. Drainage of foul-smelling pus at surgery suggests that anaerobic bacteria may have been present in two infants from whom E. coli and S. aureus were isolated [136,142].…”

“…Although a few infants are afebrile when first evaluated, a palpable mass is almost always present. Abscesses are usually 6 to 8 cm in diameter, with some containing 200 mL of pus [133] and measuring 12 cm in diameter [134] or crossing the midline [146].…”