International Journal of Clinical Medicine, 2013, 4, 455-458
http://dx.doi.org/10.4236/ijcm.2013.410081 Published Online October 2013 (http://www.scirp.org/journal/ijcm)
Adrenal Hemorrhage as a Rare Cause of Neonatal Anemia
Associated with Hydrocephalus Secondary to
Intraventricular Hemorrhage—A Case Report*
Krushnakumar Kesan#, Rahul Kumar Gupta, Paras Kothari, Abhaya Gupta, Ritesh Ranjan,
Kedar Mudkhedkar, Parag Karkera
MCh Pediatric Surgery, Department of Pediatric Surgery, LTMMC & LTMGH Sion, Mumbai, India.
Email: #krishnakesan@rediffmail.com
Received May 8th, 2013; revised June 10th, 2013; accepted July 13th, 2013
Copyright © 2013 Krushnakumar Kesan et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Neonatal adrenal hemorrhage is frequently associated with birth trauma, perinatal asphyxia, intrauterine infection, co-
agulation defects and thromboembolism. It has varied clinical presentation depending on degree of hemorrhage and
amount of adrenal cortex compromised by hemorrhage. The most common clinical presentations are persistent jaundice
and flank mass. We report a case of left sided adrenal hemorrhage in a breech delivered male neonate with perinatal
asphyxia presented with anemia and fever. On further evaluation, he was also having moderate communicating hydro-
cephalus secondary to intraventricular hemorrhage. The adrenal hemorrhage was managed conservatively. Subsequent
abdominal ultrasound showed resolving adrenal hemorrhage. Right ventriculoperitoneal shunt was done for hydro-
cephalus. Postoperative course was uneventful. The patient is asymptomatic at follow-up.
Keywords: Adrenal Hemorrhage; Neonatal Anemia; Hydrocephalus; Intraventricular Hemorrhage
1. Introduction
The adrenal gland in neonatal age is vulnerable to hem-
orrhage because of its large size and high vascularity [1].
The incidence of adrenal hemorrhage in detected cases
ranges from 1.7 to 2.1 per 1000 births. Because adrenal
bleeding may remain asymptomatic, the real occurrence
is probably higher [2]. Neonatal adrenal hemorrhage is
frequently associated with birth trauma, perinatal as-
phyxia, intrauterine infection, coagulation defects and
thromboembolism [1,3]. Adrenal hemorrhage usually
presents with neonatal jaundice, paleness and/or flank
mass, discoloration of the scrotum, anemia and adrenal
insufficiency [4-6]. In this report, we present a rare case
of neonatal adrenal hemorrhage having anemia and hy-
drocephalus.
2. Case Report
A 25-day-old, 2.8 kg, male neonate was referred to us
with complaint of fever and severe anaemia. Records
revealed that he was born of nonconsanguineous mar-
riage, fullterm, breech delivered with history of delayed
cry. APGAR scores were 4 and 5 at 1 and 5 minutes,
respectively. Patient was admitted to intensive care unit
for perinatal asphyxia.
On general examination gross pallor was evident and
there was no icterus. An abdominal mass was palpated in
the left flank. In addition, the baby was having wide open
anterior fontanels.
Haematological investigations were suggestive mi-
crocytic hypochromic anaemia (Hb 6.2 gm%, Platelet
count 7.1 lac/cu mm). Renal function and liver function
tests including coagulation profile were normal. Blood
culture and urine culture were sterile. TORCHS’ test
[toxoplasmosis, other infections, rubella, cytomegalovi-
rus (CMV), and herpes simplex virus (HSV)] was also
negative.
Abdominal ultrasound showed a well defined hypoe-
choic lesion in left suprarenal area, of size 4 × 3 cm, at
the upper pole of the left kidney suggestive of adrenal
mass which could be either neuroblastoma or adrenal
hemorrhage. The margins between the mass and the left
kidney were indistinct. Contrast enhanced computerised
tomography (CECT) abdomen revealed a 3 × 3.5 × 4 cm
*Conflict of interest: NIL.
#Corresponding author.
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Adrenal Hemorrhage as a Rare Cause of Neonatal Anemia Associated with Hydrocephalus Secondary
to Intraventricular Hemorrhage—A Case Report
456
sized well defined cystic density lesion with enhancing
walls in left paravertebral region suggestive of adrenal
hemorrhage with superadded infection (Figures 1(a) and
(b)). USG and CT skull revealed moderate dilatation of
all four ventricles. CT also revealed intraventricular
hemorrhage in right temporoparital region (Figure 2).
Serum cortisol level and 24 - hour urinary vanillyl
mandelic acid (VMA) levels were normal, which ruled
(a)
(b)
Figure 1. CECT abdome n showing we ll defined cystic de nsity le sion with enhancing walls in left paravertebral region sugges-
tive of adrenal hemorrhage.
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Adrenal Hemorrhage as a Rare Cause of Neonatal Anemia Associated with Hydrocephalus Secondary
to Intraventricular Hemorrhage—A Case Report
457
Figure 2. CECT abdome n showing we ll defined cystic de nsity le sion with enhancing walls in left paravertebral region sugges-
tive of adrenal hemorrhage.
out neuroblatoma as a differential diagnosis.
The patient was initially managed with blood transfu-
sions and intravenous antibiotic. Adrenal haemorrhage
was managed conservatively. Subsequent serial abdomi-
nal ultrasound done at 1 week interval for 2 weeks
showed gradual reduction in size of adrenal hemorrhage.
Ventricular CSF was tapped showing plenty of RBC.
Patient was kept on oral acetazolamide and CSF tap re-
peated. Right ventriculoperitoneal shunt was done for
hydrocephalus when CSF was clear. Postoperative course
was uneventful. The patient is asymptomatic at 6 months
of follow up and USG at 6 months showed complete
resolution of hemorrhage.
3. Discussion
Adrenal hemorrhage is a relatively uncommon condition
frequently seen in term male infants delivered vaginally
[7,8]. The incidence of detected cases ranges from 1.7 to
2.1 per 1000 births [4]. Adrenal hemorrhage is more
common in neonates than in children or adults because of
large size (relative to body weight gland is 10 to 20 times
larger than adults) and unique blood supply. It is supplied
by subcapsular plexus formed by fifty to sixty arterial
branches from three suprarenal arteries. This plexus is
drained into medullary sinusoids via a very few venous
channels. In case of hypoxia due to any cause there oc-
curs shunting of blood from vital organ to adrenal gland
which resulting into hemorrhage. Various predisposing
factors are birth trauma, perinatal asphyxia, intrauterine
infection, coagulation defects and thromboembolism, or
it can be spontaneous.
There is a male predominance for this condition. Right
side is more commonly affected than left and 5% - 10%
cases may be bilateral [9]. Right adrenal gland is more
susceptible, as it is more likely to be compressed be-
tween the liver and spine and, the right adrenal vein usu-
ally drains directly into the inferior vena cava, so it is
prone to changes in venous pressure.
Adrenal hemorrhage may be asymptomatic or may
presents with neonatal jaundice, paleness and/or flank
mass, discoloration of the scrotum, anemia and adrenal
insufficiency [4]. Clinical presentations depend on de-
gree of hemorrhage and amount of adrenal cortex com-
promised by hemorrhage. Our patient was having anemia
with flank mass, in addition moderate communicating
hydrocephalus and intraventricular hemorrhage.
In case of neonatal adrenal hemorrhage it is very im-
portant to rule out neuroblastoma particularly the cystic
form. 24-hour urinary excretion of VMA should be done,
since an increase in VMA is virtually diagnostic of
neuroblastoma [10]. Other differential diagnosis of AH
are neonatal adrenal abscess, cortical renal cyst, ob-
structed upper cortical renal cyst and an obstructed upper
excretory tract in the duplicated kidney [11].
Diagnosis is established with USG and CECT abdo-
men. Serial abdominal USG are more helpful as they
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Adrenal Hemorrhage as a Rare Cause of Neonatal Anemia Associated with Hydrocephalus Secondary
to Intraventricular Hemorrhage—A Case Report
458
show resolving adrenal hemorrhage. The pattern of echo-
genicity of an adrenal hematoma depends on its age. An
early-stage hematoma appears solid with diffuse or in-
homogeneous echogenicity. As liquefaction occurs, the
mass demonstrates mixed echogenicity with a central
hypoechoic region and eventually becomes completely
anechoic and cyst like. Calcification can appear as early
as 1 - 2 weeks after hemorrhage.
Presentation of adrenal hemorrhage with neonatal
anemia, flank mass has been reported by number of au-
thors [2,12]. But association between adrenal hemor-
rhage and hydrocephalus has not been reported in litera-
ture. Both conditions can be attributed with common
etiological factor of perinatal asphyxia.
4. Conclusion
In case of neonatal anaemia with perinatal asphyxia, ad-
renal haemorrhage should be suspected. Most of adrenal
haemorrhage resolves with conservative. Our patient was
having adrenal hemorrhage and hydrocephalus secondary
to intraventricular hemorrhage.
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