Endocrine Abstracts

70-year-old male patient was referred by GP on account of low blood pressure and falling platelet levels. He reported persistent shortness of breath, lethargy and reduced exercise tolerance alongwith 2 stones weight loss with poor appetite in the last 4 months. He has a background history of corneal transplant and was on immunosuppressant therapy including mycophenolate mofetil which was tapered and then stopped few weeks ago when his GP first noticed the low platelet count. His baseline blood tests on admission showed Platelet 51 (109 a month ago), WBC 9.6, Hb 111, CRP 129, Na 131. Since admission, he had continuous temperature spikes thus blood cultures were sent and started on broad spectrum IV antibiotics for sepsis of unknown source. CT- TAP was done given the history of weight loss and it showed a large lobulated left suprarenal mass, probably a confluent lymph nodal in origin with likely involvement of the left adrenal gland and marked splenomegaly. No lymphadenopathy elsewhere. The main differential was between lymphoproliferative disorder and primary adrenal malignancy. His plasma metanephrines, ACTH, aldosterone: renin ratio, cortisol and dexamethasone suppression test tumor markers, hepatitis and myeloma screen were normal EBV PCR was 1420 IU/ml. Thus, US guided biopsy was done to establish a histological diagnosis which demonstrated CD45 positive non-Hodgkins lymphoma, likely high-grade. Patient was referred to lymphoma MDT, reviewed by hematology team and he is now awaiting his first cycle of chemotherapy. Conclusions This case highlights the importance of histology diagnosis in an atypical presentation of adrenal mass. Biopsy of adrenal mass is rarely taken due to high risks such as adrenal hemorrhage or hypertensive crisis. However, in this patient with a history of acute drop in platelet count and the presence of red flags with normal adrenal work up justified the biopsy.