Introduction: A previously well 77 year old gentleman presented with syncope and dizziness in January 2012. He was found to have hyponatraemia and hyperkalaemia. As part of a work up for renal failure, a chain of investigations led towards a CT abdomen with contrast being performed. This led to the discovery of bilaterally enlarged adrenals and splenomegaly. He was noted to have thyrombocytopenia, and a subsequent bone marrow biopsy in February 2012 revealed a low grade lymphoma. Biochemical investigations into the bilaterally enlarged adrenal masses revealed raised ACTH levels, a positive short synacthen test, and subnormal cortisol and aldosterone levels. His adrenal autoantibody titres were negative. He was discharged on cortisone acetate.

Follow up: He was subsequently readmitted in May 2012 with fevers and abdominal pain. CT Adrenals revealed increased size of the bilateral adrenal masses, right side 61mm and left side 94 mm, of irregular margins and heterogeneous appearances. He underwent adrenal biopsy, which subsequently revealed large B-cell lymphoma on biopsy. He is presently undergoing chemotherapy.

Conclusions: Less than 100 cases of confirmed adrenal insufficiency due to local metastases have been published (1). For any tumour to cause adrenal insufficiency, it has to destroy 90% of the glandular tissue in both adrenal glands (2). Although adrenal metastases are well known to occur in most metastatic solid organ malignancies, adrenal insufficiency resulting from this lymphomatous infiltration has been rarely described (3).

References:

1) Lam KY, Lo CY: Metastatic tumours of the adrenal glands: a 30-year experience in a teaching hospital, Clin Endocrinol 2002;56:95–101.

2) Kung AW, Pun KK, Addisonian crisis as presenting feature in ‘malignancies’. Cancer 1990; 65: 177-9

3) JF Blaikley, P Atkinson, M Almond: Cutaneous T-cell Lymphoma
with Adrenal Insufficiency, J R Soc Med 2003; 96: 503-504