Endocrine Abstracts

Introduction: Amiodarone use may be associated with secondary severe organ dysfunction. Thyrotoxicosis develops in 15% cases. Primary bilateral adrenal lymphoma is a rare malignancy. If frequently presents bilaterally and with symptoms of adrenal insufficiency. Symptomatology for both conditions is nonspecific, especially in the elderly, and a high suspicion index is necessary for appropriate diagnosis.

Case report: A 78 year old female presented to the emergency department due to confusion, nausea and vomiting. She had history of Diabetes Mellitus, Hypertension and atrial fibrillation. She had been recently treated for urinary infection associated with vomiting and acute hypochloremic hyponatemia. Leucocyturia persisted and due to TSH 0.01 μU/ml, fT4 68 (10–18) pmol/l, fT3 6.34 (4–8) pmol/l, the patient was admitted to the Endocrinology ward. Further evaluation supported amiodarone-induced type 2 thyroiditis. Despite appropriate therapy, thyroid function further aggravated. She synchronously developed a septic state associated with nosocomial pneumonia. Hemodynamic instability, hyponatremia, hypoglycemia and vomiting raised the suspicion of concomitant adrenocortical insufficiency. Fluid resuscitation and hydrocortisone led to clinical improvement, with high dose glucocorticoid requirements. Adrenal insufficiency was admitted. Abdominal echography showed right and left justa-renal heterogeneous solid nodules (6.6 and 7 cm respectively) and left pleural effusion. Fluid analyses was negative for malignant cells. Thoracoabdominal contrasted-tomography suggested an endobronchic primary, also suspected during bronchofibroscopy, with hepatic and adrenal secondary deposits. The left mass compressed the ureter and seemed to penetrate the kidney and vascular structures. 24 h-Urinary metanephirnes were normal but the adrenals were not accessible to biopsy. After a period of seemingly favourable evolution the patient died. Autopsy confirmed primary adrenal non-hodgkin lymphoma.

Conclusion: Primary adrenal lymphoma is a rare cause of adrenal insufficiency but progression is often fast and fatal. This entity must integrate the differential diagnosis, especially in the elderly patient.