Bilateral Adrenal Calcifications as an Imaging Clue to Wolman Disease in Early Infancy: A Case Report

Wolman disease is a rare autosomal recessive lysosomal storage disorder caused by mutations in the LIPA gene, resulting in lysosomal acid lipase (LAL) deficiency and subsequent accumulation of triglycerides and cholesterol esters in multiple organs. We report the case of a two-month-old female infant with an insidious clinical course characterized by vomiting, postprandial abdominal distension, diarrhea, and failure to thrive, associated with hepatomegaly. Laboratory evaluation revealed markedly reduced total cholesterol, low-density lipoprotein, and high-density lipoprotein levels with elevated triglycerides. Abdominal ultrasound demonstrated hepatosplenomegaly with diffuse increased hepatic echogenicity consistent with steatosis and bilateral adrenal enlargement with coarse echogenic foci producing posterior acoustic shadowing, suggestive of adrenal calcifications. These findings were confirmed on contrast-enhanced abdominal computed tomography, which showed the characteristic adreniform preservation of this disease. Given the suspicion of a lysosomal storage disorder, genetic testing identified a homozygous nonsense mutation in LIPA, and enzymatic analysis confirmed markedly reduced LAL activity, establishing the diagnosis of Wolman disease. Enzyme replacement therapy was initiated, with a favorable clinical response. This case highlights the critical role of imaging findings, particularly bilateral adrenal calcifications with preserved morphology, in raising early suspicion of Wolman disease and facilitating timely diagnosis and treatment.