Endocrine Abstracts

A 49-year-old previously healthy man suddenly felt severe and constant bilateral lumbar pain. Clinical examination was otherwise normal. Abdominal CT scan showed subacute hematomas in both adrenal glands (sized 10 cm right and 8 cm left). Basic laboratory tests were completely normal. Hormonal testing excluded pheochromocytoma and other hormonally active adrenal tumors. Adrenal insufficiency was confirmed by short Synacthen test and substitution therapy with hydrocortisone was introduced. Mineralocorticoid supplementation was not needed. Prolonged closure times and platelet dysfunction on aggregometry were also found. History for previous bleeding episodes in the patient and his family was negative. Tests for antiphospholipid syndrome were borderline positive. Repeated abdominal ultrasound (US) examinations showed a decrease in size of both adrenal hematomas, so the patient was discharged with hydrocortisone supplementation. Three weeks later, few days before the planned outpatient follow-up visit, patient sought medical help because of worsening bilateral lumbar pain and extreme weakness. Diagnosis of adrenal crisis was made, so he was admitted and treated with intravenous hydrocortisone and analgesics. Several follow-up US exams showed a gradual increase in size of both adrenal hematomas. Follow-up CT scan confirmed further hemorrhage in both adrenals, the diaphragm and the lower part of the left kidney. Angiographically, several microaneurysms were shown in the parenchyma of both kidneys, without active bleeding. Only on contrast-enhanced US solid formations in both adrenals and in left kidney were visible. Fine needle aspiration biopsy of the tumor in the right adrenal was not diagnostic, however, histological biopsy confirmed diffuse large B-cell lymphoma. 18F-FDG-PET-CT showed disseminated disease with the involvement of both adrenals, kidneys, small intestine and pelvis. The patient was transferred to oncology. Bilateral adrenal bleeding is most commonly caused by trauma, anticoagulation treatment, sepsis, surgery, antiphospholipid syndrome, bilateral pheochromocytoma or metastases. Of note, radiological picture of bilateral adrenal bleeding may be mimicked by lymphomas and bilateral metastases of malignant melanoma. When solid tissue is confirmed by imaging, definitive diagnosis could be made by biopsy, but only after exclusion of pheochromocytoma. Large, bilateral adrenal tumors may cause Addison’s disease, which, if left unrecognized, may also endanger the patient.