An Incidental Finding of Bilateral Adrenal Lymphoma

A16-year-old boy was referred for back pain, arisen after a volleyball game. He was an athlete in apparent good health and did not complain of fever or any other symptom. Clinical examination was unremarkable; height, weight and blood pressure were normal. Abdominal ultrasound revealed bilateral adrenal masses, confirmed at computed tomography. Contrastenhanced computed tomography images (Figure A) of the abdomen showed bilateral retro-peritoneal suprarenal masses (arrows). The kidneys were displaced with vascular encasement. In absence of any sign or symptom of adrenal diseases, they were considered bilateral adrenal incidentalomas. When adrenal masses occur bilaterally (15% of adrenal incidentaloma), the most likely diagnoses are metastatic disease, congenital adrenal hyperplasia, bilateral cortical adenomas and infiltrative disease of adrenal glands. According to guidelines, the patient underwent tests that ruled out subclinical cortisol-secreting lesions or aldosterone-secreting lesions and pheochromocytoma. Elevated lactate dehydrogenase levels were the only abnormal biochemical finding (1,038 UI/L). Needle biopsy of the adrenal mass allowed us to make a histological diagnosis of diffuse large B-cell lymphoma according to the World Health Organization classification of 2008. Figure B shows the histology of diffuse large B-cell lymphoma. Scintigraphy and bone marrow biopsy showed skeletal and bone marrow involvement, consistent with stage IV. Primary adrenal lymphoma is a rare entity with fewer than 200 cases reported. It is defined as an histologically proven lymphoma involving one or both adrenal glands with no history of lymphoma elsewhere. Primary adrenal lymphoma usually affects elderly males and is bilateral in about 70% of the cases. It has a strong tendency to cause clinical symptoms (fever, adrenal insufficiency and weight loss); only 1% of tumors were found incidentally. To our knowledge, it is the first case in an adolescent patient and, what is more striking, it should be considered incidentally discovered.