PRIMARY ADRENAL LYMPHOMA WITH PRIMARY ADRENAL INSUFFICIENCY

A CASE REPORT

Abstract

INTRODUCTION/BACKGROUND
Primary adrenal lymphoma is a rare form of lymphoma and affects bilateral adrenal glands in most cases. This condition is often associated with adrenal insufficiency. We hereby report a case of bilateral primary adrenal lymphoma presenting with adrenal insufficiency in our centre.

CASE
A 58-year-old male with underlying hypertension presented with a 3-month history of dull lower abdominal pain, nausea, anorexia, postural giddiness, tiredness and weight loss of 5 kg. He denied any history of fever or night sweats. At presentation, his blood pressure was 116/70 mmHg despite not taking his three antihypertensive medications for the past few days. Abdominal examination revealed bilateral flank fullness. Blood investigations showed hyponatraemia and hyperkalaemia. On clinical suspicion, early morning cortisol was sent and came back at 322 nmol/L, which was considered low in an ill patient. He was managed as adrenal insufficiency and was started on hydrocortisone replacement. Subsequently, a computed tomography (CT) of the thorax, abdomen and pelvis with adrenal protocol was performed which revealed bilateral suprarenal masses with locoregional invasion. Further workup showed elevated Lactate Dehydrogenase (LDH). Tuberculosis workup and fungal culture and sensitivity were all negative. Biopsy and histopathological examination of the left suprarenal lesion revealed diffuse large B-cell lymphoma. Chemotherapy was initiated during the admission. Unfortunately, his stay was complicated with septic shock secondary to pneumonia post induction of chemotherapy. He completed a 10-day course of antibiotics and inotropes were weaned off prior to discharge. He was advised to follow up for reassessment prior to commencing the subsequent chemotherapy cycles.

CONCLUSION
Primary adrenal lymphoma is rare. However, this diagnosis should be considered in a patient presenting with bilateral adrenal masses and adrenal insufficiency. In such cases, an early adrenal biopsy is crucial to confirm the diagnosis.