Primary adrenal lymphoma presenting with symptomatic hypercalcaemia

A 66 year old male, originally from the Philippines, was referred to the emergency department with nausea, vomiting, weight loss and right flank pain. His past medical history was significant for hypertension, gout and stage 3b chronic kidney disease. On examination he was hypertensive and hyperpigmented. Laboratory investigations revealed a corrected calcium of 3.79 mmol/l (2.20–2.60), parathyroid hormone (PTH) < 0.6 nmol/l (1.6–6.9), 25OHD 49 nmol/l. He was treated with intravenous (IV) 0.9% saline followed by IV zoledronic acid. Computerised tomography of the thorax, abdomen and pelvis (CT TAP) as well as a positron emission tomography (PET) scan was performed to look for malignancy. These demonstrated bilateral metabolically active adrenal masses with no evidence of extra-adrenal disease. There were no radiological features suggestive of adrenocortical carcinoma (ACC) or phaeochromocytoma and subsequent biochemical investigations confirmed no evidence of endocrine excess. Adrenocorticotrophic hormone (ACTH) levels were elevated however, and a synacthen test revealed inadequate adrenal reserve (peak cortisol 214 nmol/l). The patient was commenced on replacement steroids and proceeded to adrenal biopsy. Histology confirmed diffuse large B cell non-Hodgkin's lymphoma (NHL) and he underwent treatment with R–CHOP regime (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisolone). Follow-up PET scan demonstrated complete radiological response.