Virilizing lipoadenoma of the adrenal gland in a pre-pubertal girl: A rare case
A 12-year-old girl presented to our hospital with a history of abnormal menstruation and progressive hirsutism. She had a normal childhood until 2 years back when she started noticing appearance of hair on her face, body, extremities and pubic region. Her height, weight and body mass index were within the normal limits. Blood pressure was 104/64 mm Hg and pulse rate was 92 beats/min. There was thick black hair on the face, arms, chest, back, legs and over the pubic region. Her breasts were pre-pubertal. Pelvic examination showed enlargement of the clitoris. Results of routine lab studies including serum electrolytes were normal.\nAbdominal and pelvic ultrasonography showed the presence of 10 cm × 8 cm sized well- defined, primarily hyperechoic mass lesion seen in the right adrenal region with indentation of the adjacent surface of liver and kidney. The uterus appeared small in size. Multi-detector computed tomography (MDCT) of abdomen, plain and contrast, showed a large well-defined heterogeneously enhancing predominantly fat attenuating lesion measuring 9.5 cm × 8.7 cm × 8.0 cm involving the right adrenal gland. The lesion demonstrated multifocal area of nodular calcification with enhancing solid component and was seen compressing the superolateral aspect of the right kidney with the minimal inferomedial displacement [Figure and ]. Blood tests were carried out for functional assessment of the right adrenal tumor. Serum testosterone level was raised to 2.24 ng/ml. Serum adrenocorticotrophic hormone, 17 hydroxyprogesterone, progesterone and cortisol levels as well as urinary 17 keto steroids, 17 hydroxy corticosteriods and vanilylmandelic acid levels were normal. A clinical diagnosis of adrenal myelolipoma was made and right adrenalectomy was performed. The specimen showed an encapsulated tumor measuring 10 cm × 8 cm × 7 cm []. Microscopic examination showed compressed adrenal tissue with foci of hemorrhage within the well- encapsulated tumor. The tumor nodules were primarily composed of eosinophilic lipid poor cells resembling zona reticularis. Mitotic rate was <5/50 hpf. No atypical mitosis was seen. The tumor nodules were separated by bands of hyalinized fibrous tissue containing proliferating thick walled vessels, hemorrhagic foci and sparse lymphocytic infiltrate. Islands of abundant mature adipose tissue were also seen. Scattered foci containing lipofuscin pigment were seen and no vascular/capsular invasion or necrosis was seen [].\nBased on the size, weight of tumor, microscopic features and Weiss criteria a final diagnosis of lipoadenoma, a morphological variant of adenoma was made.\nPost-operatively serum testosterone level returned to 0.158 ng/ml, which was within the normal limits. Patient's menstrual cycles regularized and features of hirsutism decreased [].