We describe three cases of bilateral adrenal masses with different aetiologies. Their clinical details are provided in table 1.
Table 1.
Clinical details
| Parameters | Case 1 | Case 2 | Case 3 |
| Age (years), sex | 23, male | 56, male | 70, male |
| Presenting manifestations | Fatigue, hyperpigmentation, weight loss | Fever, fatigue, weight loss, postural giddiness | Progressive worsening anaemia |
| Lag time (months) | 12 | 8 | 2 |
| Concurrent disease | None | None | Immune haemolytic anaemia |
| Blood pressure (BP) (mm Hg) | 90/70 | 70 systolic | 90/70 |
| Postural BP fall (mm Hg) | 10/10 | -/- | 20/0 |
| Haemoglobin (g/dl) | 13.4 | 12.3 | 6.4 |
| Potassium (mEq/l) | 4.2 | 4 | 4.9 |
| Cortisol 08.00 h (normal 171–536 nmol/l) | 58.6 | 59 | 484.6 |
| Peak cortisol to Synacthen (normal ⩾500 nmol/l) | 111.1 | 115 | 543.3 |
| DHEA(S) (normal 44.3 – 331 mg/dl) | 88.2 | 7.97 | 15.5 |
| Imaging | Right adrenal 4.4×2.2 cm and left adrenal 2.2×1.6 cm with a speck of calcification (fig 1A) | Right adrenal 5.5×3.0 cm and left adrenal 4.0×2.5 cm. No lymphadenopathy (fig 2A) | Right adrenal 9.2×5 cm and left adrenal 7.5×4.9 cm with periaortic lymphadenopathy (fig 3A) |
| Fine needle aspiration cytology | Granulomatous lesion consistent with tuberculosis, AFB stain is positive (fig 1B) | Periodic acid-Schiff (PAS) positive rounded structures consistent with histoplasmosis (fig 2B) | Discrete immature lymphoid cells with scanty vacuolated cytoplasm and mildly pleomorphic nuclei and fine nuclear chromatin. (May-Grunwald-Giemsa stain ×440)(fig 3B) |
| Treatment | Hydrocortisone, fluodrocortisone, anti-tubercular chemotherapy | Liposomal amphotericin, insulin, metformin | Rituximab, cyclophosphamide, hydroxyl doxorubicin, oncovin, prednisolone |
Figure 1.
(A) Contrast enhanced abdominal computed tomography (CT) scan showing bilateral adrenal masses (right adrenal 4.4×2.2 cm and left adrenal 2.2×1.6 cm) with a speck of calcification. (B) Fine needle aspiration cytology smear showing granulomatous lesion consistent with tuberculosis; AFB stain is positive.
Figure 2.
(A) Contrast enhanced abdominal CT scan showing bilateral adrenal masses (right adrenal 4.3×2 cm and left adrenal 4.9×3 cm); no lymphadenopathy. (B) Fine needle aspiration cytology smear showing periodic acid-Schiff (PAS) positive rounded structures consistent with histoplasmosis.
Figure 3.
(A) Contrast enhanced abdominal CT scan showing bilateral adrenal masses (right adrenal 9.2×5 cm and left adrenal 7.5×4.9 cm) with periaortic lymphadenopathy. (B) Fine needle aspiration cytology smear showing discrete immature lymphoid cells with scanty vacuolated cytoplasm and mildly pleomorphic nuclei and fine nuclear chromatin. (May-Grunwald-Giemsa stain × 440)
The differential diagnosis of bilateral adrenal masses1 include infective aetiologies such as tuberculosis and histoplasmosis2; infiltrative disorders such as metastasis from an unknown primary, non-Hodgkin’s lymphoma3; amyloidosis and neoplasias such as bilateral pheochromocytoma and adrenocortical carcinoma. Rarely, longstanding untreated congenital adrenal hyperplasia and macronodular adrenal hyperplasia may also be associated with bilateral adrenal masses. Imaging is usually unrewarding for establishing the aetiological diagnosis, except for the presence of calcification which may point towards the diagnosis of tuberculosis or histoplasmosis. Fine needle aspiration cytology is useful in patients with bilateral adrenal masses, especially in the presence of adrenal insufficiency.
Footnotes
Competing interests: None.
Patient consent: Patient/guardian consent was obtained for publication.
REFERENCES
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