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An incidental finding

Dr.Ibrahim Mokhtar
Monday 31.10,2016

A 68 year old man

presented with abdominal


pain and underwent
abdominal radiography.
What finding is present on
the radiograph ?

Anteroposterior abdominal
radiograph

Answer
Calcification of the adrenal

glands bilaterally

showing calcifications in paravertebral


region at level of T12/L1 (black arrows),
within adrenal glands

Follow up
The patient underwent

computed tomography, which


confirmed bilateral adrenal
calcification and no masslesion
(fig 3 arrows)..

computed tomography scan at level


of T12, showing calcifications (white
arrows)

Discussion
Differential diagnoses for adrenal

calcification include p:
revious infection (tuberculosis),
previous haemorrhage (trauma,
coagulopathy),
adrenal tumours
(pheochromocytoma, adrenal
adenoma, metastases), and
conditions such as Wolman disease.

Discussion
In this particular case the

adrenal calcification is likely to


have been caused by previous
tuberculosis infection; the
patient gave a history of
tuberculosis during childhood

Discussion
Anatomical destruction of the

adrenal glands can lead to


adrenal insufficiency, and this
is important to consider in
patients presenting acutely, as
they can be at risk of adrenal
crisis precipitated by infection,
surgery, or trauma.

Discussion
Between 7% and 20% of

patients with long standing


tuberculosis who have adrenal
involvement, such as adrenal
calcification, go on to develop
adrenal insufficiency

Recovery of adrenal function is

known to occur after antituberculosis treatment, although


this is rare. In the United Kingdom
tuberculosis is less common than
in other countries; however, this
should not be overlooked as a
diagnosis when an incidental
finding of adrenal calcification
occurs.

Learning points
include consideration for further imaging

when determining an underlying cause for


adrenal calcification.
This often poses a challenge however,
although exclusion of a mass lesion is
important.
Biochemical markers are an important
investigation when considering adrenal
function in patients with calcified adrenal
glands, particularly in those presenting
acutely or undergoing surgical intervention
who are at risk of adrenal crisis.

Reference
BMJ 2016;355:i5419 doi:

10.1136/bmj.i5419 (Published
26 October 2016)