Introduction: Adrenal incidentalomas are increasingly detected with the widespread use of imaging, whereby the large or heterogeneous lesions often raise concern for adrenocortical carcinoma (ACC). However, certain rare benign and infectious conditions may closely mimic malignant features, posing a diagnostic challenge. Case: A 64-year-old female with diabetes mellitus, hypertension, and dyslipidemia was noted to have progressively rising alkaline phosphatase during routine follow-up. She had non-specific gastrointestinal symptoms. A computed tomography abdomen pelvis showed a large, lobulated mass at the left flank, likely of adrenal origin. An adrenal protocol computed tomography revealed a large, heterogeneously enhancing left suprarenal mass measuring 10.7 × 10.3 × 10.7 cm, with a plain-phase attenuation of +81 Hounsfield Unit and absolute (28%) and relative (18%) washout. The right adrenal gland was normal, with no evidence of distant metastasis. Hormonal evaluation showed normal 24-hour urinary metanephrines, excluding pheochromocytoma. The overnight dexamethasone suppression test demonstrated cortisol of 89 nmol/L, suggestive of mild autonomous cortisol secretion, without clinical features of overt hypercortisolism. DHEA was low (0.371 µmol/L), and adrenocorticotropic hormone was suppressed (1.26 pg/mL). Evaluation for primary aldosteronism was not done due to the absence of resistant hypertension or hypokalemia. The gonadotropin profile was consistent with postmenopausal status (follicle-stimulating hormone (89 IU/L) and luteinizing hormone (28.9 IU/L) with low estradiol. The patient underwent open left adrenalectomy. Histopathology revealed an adrenal cavernous hemangioma with extensive hemorrhage and infarction, alongside necrotizing granulomatous inflammation with numerous intracellular fungal organisms and narrow-based budding yeast forms, highly suggestive of histoplasmosis, with no evidence of malignancy. She was subsequently comanaged with infectious disease team and commenced on intravenous amphotericin B. Conclusion This is a rare coexistence of an adrenal hemangioma and histoplasmosis, presenting as a large adrenal mass mimicking ACC. The limitations of imaging in differentiating benign from malignant adrenal lesions are revealed and emphasize the role of histopathological confirmation. Increased awareness of such entities can support the diagnosis and management.
Neoplasms

Background: Managing potential COVID-19 patients is challenging when resources were limited. The objective of this study was to evaluate the predictive parameters and management strategy for potential COVID-19 cases who are without contact or travelling history. Methods: Retrospective study of potential COVID-19 patients without direct contact or travelling history, admitted to Hospital Tuanku Ja’afar Seremban. Patients were riskstratified to either low or medium risk and admitted to designated wards, respectively. They were categorised to severe acute respiratory infection (SARI); influenzalike illness (ILI); dengue fever or viral fever like (DVF); or none. Clinical, laboratory and radiological variables were evaluated for predictive value. Positive cases were isolated to negative pressure isolation rooms and the neighbouring patients underwent surveillance. Results: 812 patients were studied, with 478 fulfilled SARI, ILI, and DVF. 18 (2.2%) of them were COVID-19 positive, and all patients in “none” group were negative. Hypoxia without dyspnoea and medium risk criteria were significant in predicting COVID-19 with p<0.01 (OR 7.18; 95% CI 2.70, 19.13) and p<0.01 (OR 35.77; 95% CI 11.25, 113.71) respectively. Absolute lymphocyte count showed no predictive value (P=0.88 95% CI -0.78, 0.90). Absolute neutrophil count ≥10 x10^9/L cells (OR 0.11; 95% CI 0.01, 0.87) helped to exclude COVID-19. Chest radiograph of 16 (88.9%) COVID-19 patients showed heterogeneous Ill-defined opacities. No nosocomial transmission occurred during this study period. Conclusion / Implication Initial attention to predictive parameter, riskstratification, clinical grouping strategy, and proper ward management helps in containment of COVID-19 and resources management without risk of nosocomial transmission.
COVID-19 ; SARS-CoV-2