Introduction: Adrenal incidentalomas are a common reason for endocrinology referral. We present a case of an incidentally discovered adrenal mass biochemically mimicking phaeochromocytoma with rapid resolution on subsequent imaging.
Case report: A 53-year-old female was found to have a 5 cm mass adjacent to the right kidney on ultrasound performed to investigate abnormal liver function tests. CT confirmed a right adrenal mass. The patient was normotensive with no clinical features of phaeochromocytoma or Cushings syndrome. 3 overnight urine collections showed raised levels of noradrenaline (95, 142 and 188 (nmol/mmol creatinine, normal range (NR) <48)) and dopamine (595, 820 and 808 (NR <300)) with normal urine adrenaline. Plasma rennin aldosterone ratio and 24 h urine cortisol was normal. INR was raised at 1.8. MIBI scan demonstrated no abnormalities. Plasma normetadrenalin and metadrenaline levels were not raised. Repeat CT and urine catecholamines 3 months after initial ultrasound demonstrated resolution of the adrenal mass and normal urine catecholamine levels.
Discussion: Following initial investigations we suspected phaeochromocytoma. The rapid resolution of this lesion, absence of underlying mass on subsequent imaging and subsequent normal metanephrines and repeat urine catecholamines makes the diagnosis of spontaneous adrenal haemorrhage likely. Adrenal haemorrhage is an uncommon condition with a variable presentation ranging from an asymptomatic incidental finding to severe abdominal pain and shock. Causes include trauma, severe stress, coagulopathy, antiphospholipid syndrome and underlying adrenal tumours. Raised urine catecholamines and hypertension mimicking phaechromocytoma in adrenal haemorrhage have been reported previously, in one case with an associated positive MIBG. In our patient we suspect adrenenal haemorrhage may be related to abnormal clotting resulting from liver impairment.
Conclusion: A resolving adrenal mass should raise suspicion of adrenal haemorrhage. Adrenal haemorrhage may be associated with markedly raised urine catecholamines in the absence of underlying phaeochromocytoma.