adrenal myelolipoma is a rare benign neoplasm , which contains mature adipose tissue and variable amounts of haematopoietic elements . most lesions are small and asymptomatic , discovered incidentally during autopsy or imaging studies performed for other reasons . here we reported a series of two cases of giant myelolipomas of the adrenal gland ; first one the largest tumor reported so far presented with massive hemorrhage and the second case introduced with its rare unreported presentation of adrenal myelolipomas i.e. a large abscess . adrenal myelolipoma is a rare and asymptomatic tumor usually discovered incidentally in less than 1% of population on autopsy or imaging performed for other reasons . there is an increasing incidence of large adrenal myelolipoma ( > 10 cm ) presenting with life threatening and recurrent retroperitoneal hemorrhage along with other complications as abscess . to avoid such a life - threatening situation , authors recommend close monitoring and consideration of urgent surgical intervention for tumors larger than 4 cm at presentation or increase in size or change in appearance during follow - up . myelolipoma was initially described by gierke in 1905 , and the term " myelolipomatoses " was coined by oberling in 1929 ( 1 ) . its overall incidence is 0.05 - 0.2% , which accounts for about 2.5 - 5% of adrenal incidentalomas with both genders equally affected . they are usually unilateral and rarely arise from extra adrenal sites like retroperitoneum , thorax and pelvis ( 2 ) . the tumor tissue myeloid to erythroid ratio of 3 to 4:1 is similar to that of bone marrow , but the number of megakaryocytes may be increased . here we reported a series of two cases of rare surgical emergencies of adrenal gland tumors . the first case was a giant adrenal myelolipoma with severe anemia secondary to massive retroperitoneal hemorrhage and the second one a giant myelolipoma presented with sepsis secondary to a large abscess . a 40-year - old male patient presented to the emergency department of our institute with sudden onset of dyspnea , dizziness and pain in upper abdomen . his pulse rate was 130/minute , blood pressure of 90/48 mmhg , respiratory rate of 30/minute and temperature of 98.60f . he was promptly resuscitated and blood was sent for cross - match and routine investigations . on evaluation , he was pale with a huge lump palpable in his abdomen . blood investigations revealed hemoglobin of 5 g / dl , a total leukocyte count of 10000/mm , a platelet count of 100 x 10 /mm and normal results of renal function tests . ultrasonography of abdomen showed a large hyperechoic suprarenal mass of 30  20 cm , which displaced the right kidney downwards . later a computed tomography ( ct ) scan was performed which revealed a 35  19 cm suprarenal mass pushing the kidney downwards . the mass was hypodense , non - enhancing with an attenuation value suggestive of fat i.e. , -19 hu in multiple areas with intralesional hemorrhage ( figure 1 ) . plasma biochemistry analysis showed free cortisol of 10.3 ug / ml , metanephrines of 20 pg / ml and normetanephrines of 46.8 pg / ml , which were within the normal limits . later with improvement of patient s general condition the resected specimen was 38  20  16 cm and weighed 5200 grams with a well circumscribed tumor showing multiple areas of hemorrhage ( figures 2 and 3 ) . the specimen was sent for histopathology , which revealed mature adipose tissue with tri - lineage hematopoietic elements without any evidence of dysplasia , which confirmed the diagnosis of adrenal myelolipoma ( figure 4 ) . his postoperative recovery was smooth and follow - up ultrasound performed at six month showed no evidence of recurrence . a 50-year - old male patient with diabetes presented to our emergency ward with fever , chills , rigors , pain in upper abdomen and vomiting since last five days . on examination , his pulse rate was 130/min , blood pressure of 86/48 mmhg , respiratory rate of 30/minute and temperature of 103.60f . he was promptly resuscitated and blood sample was sent for cross - match and routine investigations . on evaluation , he was pale with a visible lump in his abdomen . blood investigations revealed a hemoglobin of 7.8 g / dl , a total leukocyte count of 22000/mm , and a platelet count of 108  10 3 /mm , creatinine of 1.93 mg / dl and a blood urea nitrogen ( bun ) of 80 mg / dl . ultrasonography of the abdomen revealed a large hypochoic area with a size of 22 x 17 cm in sub hepatic location . later ct was performed , which revealed a 23  21 cm right suprarenal mass with fat and fluid density within it , pushing the kidney downwards ( figure 5 ) . once the patient s general condition improved , he was scheduled for laparotomy and a mass was excised after draining the abscess ( figures 6 and 7 ) . the specimen was sent for histopathological analysis , which confirmed the diagnosis of an adrenal myelolipoma . microscopic examination revealed that the tumor included mature adipose tissue without nuclear atypia in the adipocytes , some fibroblast , focally hematopoietic cells , and areas of hemorrhage , necrosis and inflammation . the drained pus was sent for culture , which showed pseudomonas sensitive to piperacillin and tazobactam ( figure 8) . a 40-year - old male patient presented to the emergency department of our institute with sudden onset of dyspnea , dizziness and pain in upper abdomen . his pulse rate was 130/minute , blood pressure of 90/48 mmhg , respiratory rate of 30/minute and temperature of 98.60f . he was promptly resuscitated and blood was sent for cross - match and routine investigations . on evaluation , he was pale with a huge lump palpable in his abdomen . blood investigations revealed hemoglobin of 5 g / dl , a total leukocyte count of 10000/mm , a platelet count of 100 x 10 /mm and normal results of renal function tests . ultrasonography of abdomen showed a large hyperechoic suprarenal mass of 30  20 cm , which displaced the right kidney downwards . later a computed tomography ( ct ) scan was performed which revealed a 35  19 cm suprarenal mass pushing the kidney downwards . the mass was hypodense , non - enhancing with an attenuation value suggestive of fat i.e. , -19 hu in multiple areas with intralesional hemorrhage ( figure 1 ) . plasma biochemistry analysis showed free cortisol of 10.3 ug / ml , metanephrines of 20 pg / ml and normetanephrines of 46.8 pg / ml , which were within the normal limits . later with improvement of patient s general condition the resected specimen was 38  20  16 cm and weighed 5200 grams with a well circumscribed tumor showing multiple areas of hemorrhage ( figures 2 and 3 ) . the specimen was sent for histopathology , which revealed mature adipose tissue with tri - lineage hematopoietic elements without any evidence of dysplasia , which confirmed the diagnosis of adrenal myelolipoma ( figure 4 ) . his postoperative recovery was smooth and follow - up ultrasound performed at six month showed no evidence of recurrence . a 50-year - old male patient with diabetes presented to our emergency ward with fever , chills , rigors , pain in upper abdomen and vomiting since last five days . on examination , his pulse rate was 130/min , blood pressure of 86/48 mmhg , respiratory rate of 30/minute and temperature of 103.60f . he was promptly resuscitated and blood sample was sent for cross - match and routine investigations . on evaluation , he was pale with a visible lump in his abdomen . blood investigations revealed a hemoglobin of 7.8 g / dl , a total leukocyte count of 22000/mm , and a platelet count of 108  10 3 /mm , creatinine of 1.93 mg / dl and a blood urea nitrogen ( bun ) of 80 mg / dl . ultrasonography of the abdomen revealed a large hypochoic area with a size of 22 x 17 cm in sub hepatic location . later ct was performed , which revealed a 23  21 cm right suprarenal mass with fat and fluid density within it , pushing the kidney downwards ( figure 5 ) . once the patient s general condition improved , he was scheduled for laparotomy and a mass was excised after draining the abscess ( figures 6 and 7 ) . the specimen was sent for histopathological analysis , which confirmed the diagnosis of an adrenal myelolipoma . microscopic examination revealed that the tumor included mature adipose tissue without nuclear atypia in the adipocytes , some fibroblast , focally hematopoietic cells , and areas of hemorrhage , necrosis and inflammation . the drained pus was sent for culture , which showed pseudomonas sensitive to piperacillin and tazobactam ( figure 8) . adrenal myelolipoma is a rare and asymptomatic tumor usually discovered incidentally in less than 1% of population on autopsy or imaging performed for other reasons . larger lesions ( i.e. > 5 cm ) can rarely present with acute retroperitoneal hemorrhage ( 3 ) . the largest myelolipoma so far was reported by boudreaux et al . which was 34 cm in size and weighed 5900 grams . the first case in our series had a larger tumor than that of boudreaux et al . although the tumor itself is nonfunctioning , there is 10% incidence of associated endocrine disorders such as cushing s disease , conn s syndrome , diabetes and congenital adrenal hyperplasia . besides although the reasons are not well known , myelolipoma in patients with thalassemia are usually giant and bilateral . the most accepted one is metaplasia of reticuloendothelial cells of blood capillaries in adrenal gland in response to various stimuli such as necrosis , inflammation , infection or stress . whether these tumors are neoplasm or relative growth , is not clear to date . a study by yildiz et al . showed nonrandom x chromosome inactivation in hematopoietic lineage and fat cells , suggestive of a clonal origin . similarly , another study performed by chang et al . demonstrated a balanced translocation between 3q 25 and 21q 11 , which was suggestive of a possible clonality in the origin of myelolipoma . our second case in the series presented with features of sepsis and anemia ; this presentation was not reported in the literature so far . possible explanation of such presentation may be due to infection , secondary to rupture of large tumor leading to abscess formation ( 6 ) . diagnosis of adrenal myelolipoma is usually made by identification of fat on various imaging modalities as us , ct and mri , which are effective to detect more than 90% of cases . it appears hyperechoic if it contains fat and hypoechoic if it has predominance of myeloid cells . tumor mass shows large amount of fat [ attenuation < 30 hounsfield units ( hu ) ] with interspersed of higher attenuation due to myeloid element . the overall attenuation values are low ( -20 to -30 hu ) and suggestive of mixture of adipose and myeloid elements . mri characteristically demonstrates high signal intensity on t1 weighted images consistent of fat , which is often found in these lesions . although , use of mri imaging can be diagnostic ( 7 ) . in cases of diagnostic dilemma , percutaneous biopsy must be considered , which can reveal mature adipocytes similar to marrow and hematopoietic cells . histological assessment is helpful in differentiation of other tumors found in the retroperitoneal area ( 8) . as such if imaging features are characteristic and lesion is small , recommended treatment is observation . as per the study of meyer the calculated doubling time of adrenal myelolipoma ranged from 4.6 to 95.1 months ( a mean of 31.9 months ) , which confirmed the relatively slow growing nature of incidental myelolipoma and suggested no need for so frequent observation of myelolipoma . however , hemorrhage and other complications occur more commonly in larger lesions ( diameter > 10 cm ) . therefore , only in cases of large symptomatic lesions or when hemorrhage has occurred , surgical excision is curative ( 9 ) . in our scenario , the first case was the largest adrenal myelolipoma reported so far with 38 x 20 x 16 cm in size presented with severe anemia secondary to acute retroperitoneal hemorrhage . while , the second case was a large adrenal myelolipoma presented with severe sepsis secondary to abscess formation . we made the initial differential diagnoses of retroperitoneal liposarcoma , liver abscess , angiomyolipoma with retroperitoneal hemorrhage , since huge myelolipoma of adrenal is a very rare pathology and acute retroperitoneal hemorrhage and abscess formation is even rarer phenomenon associated with it , so we kept it as the last differential diagnosis in our list ( 10 ) . there is an increasing incidence of large adrenal myelolipoma ( > 10 cm ) presenting with life threatening and recurrent retroperitoneal hemorrhage along with other complications as abscess . to avoid such a life - threatening situation , authors recommend close monitoring and consideration of urgent surgical intervention for tumors larger than 4 cm at presentation or increase in size or change in appearance during follow - up .
introduction : adrenal myelolipoma is a rare benign neoplasm , which contains mature adipose tissue and variable amounts of haematopoietic elements . 
 most lesions are small and asymptomatic , discovered incidentally during autopsy or imaging studies performed for other reasons.case presentation : here we reported a series of two cases of giant myelolipomas of the adrenal gland ; first one the largest tumor reported so far presented with massive hemorrhage and the second case introduced with its rare unreported presentation of adrenal myelolipomas i.e. a large abscess.discussion:adrenal myelolipoma is a rare and asymptomatic tumor usually discovered incidentally in less than 1% of population on autopsy or imaging performed for other reasons . 
 there is an increasing incidence of large adrenal myelolipoma ( > 10 cm ) presenting with life threatening and recurrent retroperitoneal hemorrhage along with other complications as abscess . 
 to avoid such a life - threatening situation , authors recommend close monitoring and consideration of urgent surgical intervention for tumors larger than 4 cm at presentation or increase in size or change in appearance during follow - up .