A 57-year-old woman, born in Curicó, with a history of moderate hypertension of approximately 6 years of evolution, well controlled, with enalapril 10 mg and hydrochlorothiazide 50 mg/day.
Asymptomatic, on June 14, 2003, the patient presented progressive asthenia, sweating, fever, no chills, headache, decreased strength and abdominal pain deaf, diffuse, permanent and vomiting.
Evaluated in Có, he was 38.2°C, regular pulse 92x’, blood pressure 110/70 mmHg and with feverish sensitivity to palpation of the right flank.
Abdominal ultrasonography and CT scan revealed a heterogeneous solid cystic, vascularized mass with calcifications of approximately 15 x 12 cm, compatible with right adrenal tumor.
The chest X-ray was normal.
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On July 2, she was admitted to the Regional Hospital of Talca for study and treatment, with diagnosis of adrenal macrotumor necrosis: cancer or pheochromocytoma.
The examination revealed a patient afflicted with colitis and a right flank sensitive and occupied by a firm mass.
There were no other relevant elements in the segmental examination.
The predominant intermittent fever was vespertine up to 39.5°C, profuse sweating, regular tachycardia 90 to 120 x’, blood pressure 90/60 to 160 mmHg.
A sample was taken for urinary catechiae.
Plasma cortisol, thyroid hormones, total testosterone and ADE-S were normal.
Normal SMA12 indices, except blood glucose 140 mg% and albumin 2.6g%; sodium 134 mEq/l, potassium 4.2 mEq/l, leukocytes 13,330 with 12% bacteria 113 mmh, hematocrit 30%.
Three blood cultures were negative.
Persistent sepsis and progressive pain with diagnosis of adrenal incidentaloma, on July 11, percutaneous puncture was performed under ultrasound guidance.
350 cc of thick, chocolatey liquid with an old appearance was aspirated.
The cytochemical study reported abundant leukocytes (>50,000/mm3) 99% polymorphonuclear, regular erythrocytes quantity, abundant pus and gram, scarce Gram (+) bacilli.
In aerobic environment, negative coagula-sa staphylococci were developed.
The procedure was perfectly performed by the patient and drainage was followed by significant pain relief.
Antibiotics were started: ceftazidime 4 g and metronidazole 1.5 g/day, ev.
persistence of fever up to 39.2°C, on July 18, it was decided to perform laparotomy and surgical drainage of the retroperitoneal abscess.
During the intervention, blood pressure remained stable between 100/60 and 150/90 mmHg.
The culture developed Corynebacterium renale.
Biopsy of the abscess-tumor wall was reported as inconclusive, with atypical cellular elements, suspicious of neoplasia.
The patient remained with two drainage tubes and antibiotic regimen was maintained.
The subsequent evolution was the clear recovery of the general state, the fever fell and the appetite and food tolerance improved.
On July 23, a result of urinary catecholamines was obtained: noradrenaline 1,184 ug and 375 ug/24 h, categorical of pheochromocytoma.
Doxozosin 4 mg/day was added.
On August 5, antibiotics were suspended and he was discharged three days later with drainages with low output and indication of nutritional supplementation, differing definitive surgery until recovery of his general condition and albumin.
Established stable, afflicted, with blood pressure between 110/70 and 140/90 mmHg.
Drains were removed on August 22.
On October 1st, albumin had improved the % a.c. and the control CT scan showed a reduction of adrenal mass to exostoses of the necrotic component.
On October 14, the patient underwent bilateral subcostal laparotomy, laborious surgery lasting 4 h, complicated by section of the renal artery, successfully repaired with dopamine and nitro/40russide crisis treated with blood hypertension up to 200/120.
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He was discharged on 20 October 2003, in good condition, without medication.
Controlled on December 3, he was well, afflicted and normotensive.
Pathologic examination of the surgical piece revealed nodular formation of 13.5x9x8 cm, 570 g, encapsulated.
Cutting, solid, reddish brown colored areas with necrotic appearance.
The rare variant is phaeochromocytoma, with low mitotic index, focal bleeding and inflammatory areas in parts xgranulomatous with giant cells.
No evidence of vascular invasion.
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The subsequent evolution was excellent, with 17 kg of weight (55 72 kg) and normal blood pressure, treated with enalapril 10 mg and hydrochlorothiazide 50 mg/day.
In October 2004, one year after surgery, a chest X-ray and abdominal CT were performed, both were normal.
