Endocrine Abstracts

: Lymphoma is one of the rare causes of bilateral adrenal gland enlargement that require a high index of suspicion for diagnosis. We present a case of 80-year-old lady referred by her GP for further evaluation after presenting with lower abdominal discomfort and weight loss for which she had a CT scan that revealed bilateral adrenal gland masses (60 HU) with the right adrenal gland measures 61 mm in diameter with distal ileal thickness and regional lymphadenopathy. She has no symptoms of carcinoid (i.e.: no flushes, wheeze or diarrhoea) or pheochromocytoma (i.e.: no palpitations or panic attacks) and does not appears particularly cushingoid or tanned with no postural drop in her BP (L: 135/80, S: 130/70). She is not smoker or alcohol consumer and her clinical examination revealed palpable nontender cervical lymphadenopathy but was otherwise unremarkable. Her biochemical profile revealed a random cortisol of 434 nmol/l (ACTH: 113 ng/l), chromogranin-A of 71 ug/l, normal plasma metanephrines and ARR. Her routine investigations including FBC, U+E & bone profile were all normal with mildly raised LDH level of 279 unit/l. She underwent further detailed investigations looking for the underlying cause including DHEAS, Androstenedione, testosterone, 17OH progesterone, tumour markers (CEA, Ca19-9, CA125, AFP), viral screening (HIV, HBV, HCV), immunoglobulins and serum electrophoresis which were all normal. After discussion in the endocrine MDT the consensus was to obtain a L.N biopsy which confirmed a diagnosis of diffuse high-grade NHL for which she was referred urgently for haematology colleagues and commenced on RGCVP chemotherapy. Patient had a lot of troubles with collapse /? hypotension in the last 14–21 days necessitating admission to A&E prior to starting her steroids. She is currently on Prednisolone 60 mg OD as a part of RGCVP therapy with advice to give pulse/tapering steroid in between to prevent adrenal crisis. In cases of adrenal enlargement, it is prudent to assess the functionality of the gland as well as looking for any suspicious radiological features considering both the density and the adenoma size. Clinician should always consider the causes of bilateral adrenal enlargement which require further investigations to provide the correct treatment and the differential diagnoses include: CAH, ACTH dependent Cushing’s, hyperaldosteronism, infiltrative causes (e.g.: lymphoma, Leukaemia\..etc) and infections (Fungi, TB\..etc). Whether our patient adrenal insufficiency will resolve after successful treatment of lymphoma remains uncertain however it is felt safer to cover her with steroids at this stage.