Endocrine Abstracts

JOINT670

Introduction: With advancements in imaging technology and its widespread use, adrenal incidentalomas have become a frequent finding. Most cases involve non-functional, irreversible adrenal enlargements. However, reports of reversible adrenal enlargements remain limited.

Case Report: We explored a 68-year-old man, with metabolic hyperferritinemia without HFE mutation and partial splenectomy, for bilateral adrenal masses suspect of malignancy. In July 2024, he had a fever and lost weight (4kgs). All infectious causes were excluded (PCR triplex (including SARS-CoV-2), tuberculosis, B/C hepatitis, HIV, tropical diseases) and an empiric antibiotic treatment was suspended after 7 days due to no improvement. After a two months fever, the PET scan (08/2024) showed one 35 mm intensely hypermetabolic left adrenal mass, 2 intensely hypermetabolic right adrenal masses (13 mm on the medial arm, 11 mm in the body) and three intensely hypermetabolic latero-aortic adenopathies. The abdominal scanner (10/2024) detailed basal density, absolute and relative wash out: left adrenal: 30 HU/36%/25%, 1st right adrenal lesion: 19 HU/82%/66% and 2nd lower right adrenal lesion: 25 HU/55%/41%. The hormonal work-up showed: normal basal ACTH (25.4 pg/ml) and cortisol values (303.9 nmol/l), an optimal response after Synacthene testing (peak at 502.3 nmol/l), correct cortisol after 1mg DST (<27.6 nmol/l), normal midnight serum cortisol (114.7 nmol/l), and free urinary cortisol/24h (28.7 mg/24h), normal serum and urinary metanephrines and normetanephrines, normal Chromogranin A, normal testosterone but a low DHEA-S [0.8 umol/l – (6.2-7.7 umol/l)] and normal 17-OH-progesterone. A surgical excision of the left adrenal mass was preferred to an adrenal biopsy or lymph node biopsy. However, the pre-surgical PET scan (11/2024) showed almost complete regression of the adrenal masses, with only a persistent diffuse and moderately hypermetabolic thickening of the left adrenal, a non-fixing right adrenal and almost complete regression of the latero-aortic adenopathies. The surgery was canceled. We retained an etiological doubt. Adrenal hemorrhage was unsuspected with first images, but an MRI performed in 11/2024 showed a few hypovascular left adrenal nodules, compatible with adrenal hematomas. SARS-CoV-2 infection may cause bilateral adrenal masses compatible with the onset of the febrile episode. Adrenal lymphomas are associated with splenomegaly (impossible to evaluate in our patient), adrenal failure and abnormal hemogram (absent) and no spontaneous regression. An adrenal biopsy will be performed if the suspicion remains high during the follow-up.