We report a case of a 57 year old lady who presented with marked weight loss, dizziness and general malaise. The physical examination revealed pallor, hypotension, tachycardia and dehydration. There was no muco-cutaneous pigmentation. Routine biochemistry showed normocytic anaemia, hyponatraemia, mild hyperkalaemia and renal impairment. Abdominal ultrasound showed presence of bilateral large supra-renal masses. A short synacthen test showed sub-optimal rise in plasma cortisol from 207 nmol/L at baseline to 289 nmol/L at 30 minutes. She was treated with intravenous fluid and hydrocortisone to correct her hypoadrenalism while awaiting further investigations. Her general condition improved with the above measures with correction of the hypotension, electrolyte imbalance and renal impairment. A CT scan of the abdomen and thorax confirmed presence of 12 cm adrenal masses bilaterally. There was no other space occupying lesion in either the abdomen or thorax. Her 24 hour urinary metanephrine estimation was normal. We biopsied the adrenal mass under ultrasound guidance. The histology showed a diffuse large B cell type Non Hodgkins lymphoma. The absence of peripheral, axial lymph node and bone marrow involvement suggested this to be a primary adrenal lymphoma. She was treated with cyclophosphamide, doxorubicin, vincristine, prednisolone and rituximab. A CT scan of the abdomen repeated after 4 cycles of chemotherapy showed complete resolution of the adrenal masses. However, after there was appearance of lymphoma in other sites and she died six months after the diagnosis.
Although secondary involvement of the adrenal gland by lymphoma is not uncommon, primary adrenal lymphoma is a rare extra-nodal non-Hodgkins lymphoma. Bilateral adrenal masses and adrenal insufficiency should raise the suspicion of primary adrenal lymphoma.