Endocrine Abstracts

A 45-year-old man presented with sudden onset left sided pleuritic chest pain and breathlessness. He was hypotensive and severely hypoxic and was admitted to the Intensive Care Unit. A chest X-ray was normal and an urgent computerised tomographic (CT) pulmonary angiogram showed the presence of extensive pulmonary emboli. The CT scan also showed bilateral adrenal “incidentalomas” with the right one being 8 cm and the left 6 cm in its longest dimension. He responded well to thrombolysis and was discharged on warfarin. Following discharge, he underwent investigations to exclude adrenal hypersecretion. 24-h urinary catecholamines, serum aldosterone, plasma renin, serum dehydroepiandrosterone sulphate and post-dexamethasone 9 am plasma cortisol were normal. Short synacthen test confirmed normal adrenocortical function. An adrenal biopsy was planned but 3 weeks after discharge, he required re-hospitalization with recurrent vomiting and weight loss and he was found to have widespread lymphadenopathy. A repeat CT scan showed that the adrenal masses now measured 28 cm and were compressing the duodenum and the inferior vena cava. A supraclavicular lymph node biopsy confirmed the diagnosis of high grade, diffuse B cell Non-Hodgkin’s lymphoma (NHL). Ki67 staining of the tumour showed a high rate of proliferation and he was started on high intensity chemotherapy with rituximab, cyclophosphamide, doxorubicin, vincristine, high dose methotrexate, high dose cytosine arabinoside and dexamethasone. He has currently completed four of the planned six cycles of chemotheraopy and has responded dramatically with subsidence of all symptoms and a significant reduction in adrenal masses on a further CT scan. The presentation of adrenal lymphomas as bilateral adrenal incidentalomas, the rapidity of enlargement of the masses, preservation of adrenocortical function and the dramatic response to chemotherapy were unusual and interesting features of this case. The diagnosis of adrenal lymphoma should be considered in patients with bilateral adrenal incidentalomas.