Adrenal enfeksiyon ve granülomatöz tutulum

Özet

Adrenal bez enfeksiyonu tüberküloz ve histoplazmoz gibi granülomatöz hastalıklarla veya ağır sistemik enfeksiyon sırasında gelişebilir; bez tutulumu çoğu kez iki taraflıdır. BT bulguları etkene özgü değildir, ancak bez büyümesi, nekroz ve çevre yağ reaksiyonu klinik enfeksiyon bağlamında adrenaliti düşündürür. Kontrastsız seri kalsifikasyonu ve kanama yoğunluğunu, portal faz ise nekrotik alanların çevresel boyanmasını, apseyi ve eşlik eden enfeksiyon odaklarını ortaya koyar. Aktif enfeksiyonu kronik atrofik-kalsifiye evreden ayıramamak veya adrenal destrüksiyonun klinik önemini fark etmemek adrenal işlev kaybının gözden kaçmasına yol açabilir.

Faz ve pencere

Kontrastsız tanısal

Aktif granülomatöz tutulumda genişlemiş adrenal bez içinde düşük atenüasyonlu nekroz; kronik hastalıkta küçük bez, noktasal ya da yaygın kalsifikasyon görülebilir. Kronik granülomatöz hastalıkta adrenal bezde atrofi ve noktasal ya da yaygın kalsifikasyonlar izlenebilir.

Portal tanısal

Aktif enfeksiyonda bez çevresinde yağ çizgilenmesi, heterojen parankim boyanması ve nekrotik merkez çevresinde rim boyanması görülebilir; eşlik eden koleksiyonlar, lenf nodları ve diğer abdominal enfeksiyon odakları incelenir.

Önerilen pencereler: Batın (G 400 / M 50), Yumuşak doku (G 400 / M 40).

BT bulguları

• İki adrenal bezde yaygın kalınlaşma veya lobüle büyüme; tüberküloz ve histoplazmozda bilateral dağılım sık görülür.
• Bez parankiminde belirgin düşük atenüasyonlu, coğrafi veya düzensiz nekrotik alanlar.
• Portal fazda nekrozun çevresinde ince ya da kalın rim biçimli kontrastlanma; odak sıvılaşmışsa adrenal apse düşünülebilir.
• Enfeksiyöz adrenalitte bez çevresinde yağ çizgilenmesi izlenebilir; enfeksiyon süreçleri primer tümörlerle karışabilecek benzer görüntüleme bulguları üretebilir.
• Kronik granülomatöz evrede küçülmüş veya atrofik bez içinde noktasal, dağınık ya da kaba kalsifikasyonlar.
• Aynı incelemede akciğer tabanları, karaciğer, dalak, böbrekler ve lenf nodlarında enfeksiyonun başka odakları bulunabilir.
• Ağır sepsis veya akut adrenal kanama bağlamında bezde hemorajik yoğunluk ve çevreye uzanan kanama eşlik edebilir.

Normalde

Normal adrenal bezler iki yanda ince, düzgün dallanan kruslardan oluşur; çevre retroperitoneal yağ planları temizdir ve bez içinde nekrotik boşluk ya da kalsifikasyon izlenmez. Enfeksiyonda karşılaştırma, bezlerin hacim ve konturunu, iki taraflı simetriyi, çevre yağın korunup korunmadığını ve kronik dönemde bezin atrofik hale gelip gelmediğini kapsar.

Ayırıcı tanı

Adrenal lenfoma

bilateral veya unilateral büyük, heterojen kitleler ve bazen invazyon gösterebilir; kesin tanı biyopsi gerektirir.

Adrenal metastaz

bilinen primer kanser, diğer metastazlar ve nodüler solid bez değişikliği ayırıcı tanıyı yönlendirir.

Bilateral adrenal hemoraji

bez içi yüksek yoğunluklu kan ve klinik akut kanama bağlamı ön plandadır.

Adrenokortikal karsinom

tek taraflı baskın, heterojen ve invaziv kitle enfeksiyondan daha çok tümörü düşündürür.

Adrenal hiperplazi

Kalıcı ACTH uyarısına bağlı bilateral bez büyümesi ve lobüle yüzey konturları görülebilir.

Tuzaklar

• Bilateral adrenal kitleyi otomatik olarak metastaz veya lenfoma diye yorumlama; enfeksiyon, özellikle nekroz ve çevre yağ reaksiyonu varsa güçlü taklitçidir.
• Kronik TB'de bezler büyümek yerine atrofik ve kalsifiye olabilir; yalnız bez boyutuna bakmak geçirilmiş granülomatöz hastalığı kaçırabilir.
• Nekrotik kitle ve rim boyanması enfeksiyona özgü değildir; bilinen malignite veya başka organ tutulumları eşlik ediyorsa neoplaziyi dışlama.
• Kalsifikasyon tek başına etkeni belirlemez; aktif nekroz, kronik bez atrofisi ve klinik sistemik bulgularla birlikte yorumla.

Kendini dene

1. Adrenal tüberkülozunda BT’de bildirilebilen görünüm hangisidir?

   • Bilateral büyümüş, heterojen düşük atenüasyonlu bezler ve ince periferik rim boyanması
   • Her iki adrenal bezde yalnızca homojen yağ atenüasyonu
   • Adrenal bezlerin normal boyutta ve kontrastlanmasız olması
   • Tek adrenal bezde kalsifikasyonsuz basit sıvı yoğunluklu kist
   Cevabı göster

   Bilateral büyümüş, heterojen düşük atenüasyonlu bezler ve ince periferik rim boyanması. Bir adrenal tüberkülozu olgusunda BT’de bilateral büyümüş, heterojen düşük atenüasyonlu adrenal bezler ve ince periferik rim benzeri kontrastlanma bildirilmiştir. Granülomatöz adrenal tutulumda büyüme, merkezi nekroz, kalsifikasyon ve kontrastlanma da görülebilir.

2. Granülomatöz adrenal enfeksiyonun aktif evresinde tipik olarak görülen BT bulgusu hangisidir?

   • Bilateral bez büyümesi ve merkezi nekroz
   • Tek taraflı kalsifiye kitle
   • Homojen yağ atenüasyonlu basit kist
   • Aşırı kontrastlanma gösteren solid lezyon
   Cevabı göster

   Bilateral bez büyümesi ve merkezi nekroz. Kaynaklar, aktif granülomatöz tutulumda bilateral bez büyümesi ve nekrozun sık görüldüğünü; kronik veya iyileşmiş evrede ise bezlerin küçülüp kalsifikasyon geliştiğini belirtmektedir.

Kaynaklar

Bu sayfadaki 36 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 5 cümle bu karşılaştırmada düzeltildi (2026-10-08).

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