Endocrine Abstracts

77-year-old male presented with a 1 year history of lethargy, anorexia, abdominal discomfort, weight loss since September 2011. He has a background of psoriasis, primary hypothyroidism (TPO normal), cataract, glaucoma and in 2003 testicular lymphoma treated with CHOP14, intrathecal methotrexate and orchidectomy.

GP assessment showed upper abdominal fullness, mild anaemia elevated ESR, ferritin and LDH hence the haematology referral. Total body CT described massively enlarged bilateral adrenal masses, right hilar lymph lymphadenopathy.

Diagnosis of adrenal dysfunction was proposed, subsequently confirmed with short synacthen test showing cortisols of 172, 193 and 174 nmol/l at baseline, 30 and 60 min (ACTH 371 ng/ml). Normal results for 24 h urine metanephrines, chromogranin A and B and adrenal antibodies.

Serum testosterone of 2.4 nmol/l, FSH (25 IU/l) and LH 22.4 IU/l) confirmed concurrent orchidectomy hypogonadism. PSA 7.2 μg/l.

There was marked improvement in his well-being, energy and appetite upon prompt hydrocortisone and fludrocortisone therapy.

CT guided adrenal biopsy histology confirmed the presence of diffuse large B cell lymphoma, similar histology to that of the 2003 testicular lymphoma.

Chemotherapy was given completed three cycles of RCHOP and followed by two cycles of RCVP (one intrathecal).

The 3 months adrenal response to chemotherapy was significant with massive adrenal lymphoma reduction. The left adrenal measured 62×18 mm (previously 97×62 mm); right adrenal 37×18 mm (previously 70×57 mm) at 3 months.

Lymphoma adrenal insufficiency is uncommon but described. This case was unusual with an 8-year gap of a recurrent lymphoma affecting two endocrine glands. Follow-up assessment demonstrated no adrenal secretory function recovery. Short Synacthen test in October 2013 results were 86, 97 and 105 nmol/l at 0, 30, 60 min, respectively. He remains fairly well.