Endocrine Abstracts

Adrenal insufficiency is not commonly associated with a finding of bilateral enlarged adrenal gland when diagnosed in late adulthood. Various cases in the literature to date seem to indicate that the combination of these two findings may be suggestive of adrenal lymphoma. Our patient was initially referred to Gastroenterology with weight loss, nausea and early satiety from where he was referred for a whole body computed-tomography (CT) scan as part of a screen for malignancy. This unexpectedly showed bilateral adrenal masses; lung nodules were also noted. Further asessment by dedicated adrenal CT scan showed no change interval increase in size with contrast washout >60% and relative washout of 40% consistent with multiple bilateral adenomata. Subsequent to this he presented via the emergency department with dizziness and collapse alongside his pre-existing symptoms. His biochemistry was significant for hyponatraemia (129 mmol/L) and a high-normal potassium (5.1 mmol/L). A Short Synacthen Test showed a complete failure of response with a significantly raised ACTH; his renin was also significantly elevated consistent with mineralocorticoid deficiency (post-synacthen Cortisol 69 nmol, ACTH 351 ng/L, Renin 115.2 mU/L). His adrenal autoantibodies were negative. Urine metanephrines were not elevated excluding phaeochromocytoma. His imaging was discussed at Urology MDT and an interval CT adrenal was arranged 6 months later. This demonstrated substantial progression of both adrenal lesions. An FDG positon emission tomography scan (PET) was performed on MDT advice which showed avid uptake in both glands. Urgent excisional adrenal biopsy was undertaken; the histology was consistent with diffuse large B-cell lymphoma. Despite urgent commencement of chemotherapy by Haematology the patient eventually passed away. This case highlights an unusual cause of adrenal insufficiency with adrenal masses and is consistent with similar cases in the literature. We would urge anyone investigating these findings to consider adrenal lymphoma as a differential in future.