Hyponatremia and Adrenal Failure as a Presenting Feature of Bilateral Adrenal Lymphoma

Program: Abstracts - Orals, Featured Poster Presentations, and Posters
Session: SUN 1-16-Adrenal Insufficiency
Clinical
Sunday, June 16, 2013: 1:45 PM-3:45 PM
Expo Halls ABC (Moscone Center)

Poster Board SUN-9
Mohamad Hosam Horani*1, Adonis Jabbour2, Mazen Khattab3, Firas Alyafi4 and Saifuldeen Al-Qaisi5
1Alsham Endocrinology, Chandler, AZ, 2Banner Baywood Hospital, AZ, 3US Oncology, AZ, 4Saint Joseph hospital, AZ, 5Saint Joseph Hospital, AZ
Introduction:

Primary adrenal lymphoma (PAL) is a rare clinical entity, accounting for less than 1% of Nonhodgkins lymphomas. It usually presents with  signs and lab findings of adrenal insufficiency (AI). Symptoms include weakness, nausea and

abdominal pain.

Case Description:

HPI:74 year old man without significant past medical history, presented to the hospital with progressive weakness and nausea for 6 weeks. His review of system was negative other than the history of present illness.

BP was 105/50 ,HR 82, RR 16, T 36.8. Physical exam was unremarkable with no skin pigmentation, no LAD or HSM. The rest of the physical examination was normal.

Labs and Findings:

WBC 3.4 , HB 12.3 gm/dl, platelets 120000 c/mcL, Na 116mEq/L , K 5.1mEq/L, Cr1.6mg/dl,  calcium 9.1mEq/dl, LDH 161U/L, Glucose 92mg/dl, normal Liver function test and normal thyroid function tests . Work up of hyponatremia showed high urine osmolality with low serum osmolality raising suspicion of SIADH . Further work up of Hyponatremia revealed low serum cortisol of 2.3 mg/dl. Serum cortisol remained low at 2.5 one hour -post cosyntropin stimulation test. Baseline ACTH level came back later significantly elevated 1135 (6-50 Pg. /mL) confirming primary adrenal insufficiency.

Imaging:

CT abdomen and  pelvis showed  enlarged adrenal glands, right adrenal glands measured 6 cm in length and left adrenal glands 4 cm in length. Chest and brain CT scans were negative for any mass. Biopsy of adrenal gland showed high grade B - cell non Hodgkin lymphoma.

Conclusion:

PAL is an extremely rare entity. It is characterized by a high incidence of bilateral adrenal involvement of diffuse large B-cell lymphoma.  Hyponatremia and subtle clinical signs of adrenal insufficiency led to a diagnosis of Addison's disease, a common complication of primary adrenal lymphoma. Thus, bilateral adrenal masses associated with Addison's disease should raise the suspicion of possible primary adrenal lymphoma

1. Mod Pathol. 2009 Sep;22(9):1210-7. Epub 2009 Jun 12

Nothing to Disclose: MHH, AJ, MK, FA, SA

*Please take note of The Endocrine Society's News Embargo Policy at http://www.endo-society.org/endo2013/media.cfm