A 66-year-old HIV positive male presented to gastroeneterologist with a 2 months history of severe fatigue, weight loss, dizziness and nausea. He had background of ulcerative colitis which was quiescent and he has not received steroids for more than 12 months. Baseline blood results revealed normal biochemistry with mild normocytic anaemia, neutropaenia and lymphopaenia. As there was a high clinical suspicion of adrenal insufficiency, the short synacthen test was performed which demonstrated intact HPA axis (baseline cortisol 348 nmol/L, 30 mins cortisol 607 nmol/L, 60 mins cortisol 632 nmol/L). Upper and lower GI endoscopies as well as CT abdomen showed no significant pathology. 3 months later he presented acutely to A&E with extreme fatigue, vomiting and hypotension. His blood tests revealed sodium of 123 mmol/L and potassium of 4.0 mmol/L. His short synacthen test was repeated and demonstrated suboptimal response this time with baseline cortisol 298 nmol/L, 30 mins cortisol 353 nmol/L and 60 mins cortisol 439 nmol/L. Steroid replacement therapy resulted in significant clinical improvement. The CT abdomen was repeated at that stage as well and revealed bilaterally enlarged adrenal glands measuring 6 cm each; they were well defined and homogeneous in appearance, thought to represent adrenal hyperplasia rather than malignancy. Endocrine tests to assess functionality proved to be negative. 3 weeks following this imaging, a CT guided biopsy to secure the diagnosis was arranged. At that time the adrenals were noted to have reduced in size by 70%, which was thought to be the consequence of the steroid replacement therapy. Also new retroperitoneal lymphadenopathy was observed. Finally, laparoscopic biopsy was performed which confirmed a diagnosis of a diffuse large B-cell lymphoma (stage IV on PET CT).
Declaration of interest: There is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.
Funding: No specific grant from any funding agency in the public, commercial or not-for-profit sector.