J Korean Med Sci.  2011 Oct;26(10):1386-1390. 10.3346/jkms.2011.26.10.1386.

Mainly Adrenal Gland Involving NK/T-Cell Nasal Type Lymphoma Diagnosed with Delay due to Mimicking Adrenal Hemorrhage

• Kang SM
• Kim WJ
• Lee KA
• Baek HS
• Park TS
• Jin HY

• KMID: 1786000
• DOI: http://doi.org/10.3346/jkms.2011.26.10.1386

Abstract

A 29-yr-old man, presented with abdominal pain and fever, had an initial computed tomography (CT) scan revealing low attenuation of both adrenal glands. The initial concern was for tuberculous adrenalitis or autoimmune adrenalitis combined with adrenal hemorrhage. The patient started empirical anti-tuberculous medication, but there was no improvement. Enlargement of cervical lymph nodes were developed after that and excisional biopsy of cervical lymph nodes was performed. Pathological finding of excised lymph nodes was compatible to NK/T-cell lymphoma. The patient died due to the progression of the disease even after undergoing therapeutic trials including chemotherapy. Lymphoma mainly involving adrenal gland in the early stage of the disease is rare and the vast majority of cases that have been reported were of B-cell origin. From this case it is suggested that extra-nodal NK/T-cell lymphoma should be considered as a cause of bilateral adrenal masses although it is rare.

Keyword

Bilateral adrenal masses; Extra-nodal lymphoma; Natural killer (NK)/T-cell nasal type lymphoma

MeSH Terms

Adrenal Gland Neoplasms/*diagnosis/pathology
Adrenal Glands/*blood supply
Adult
Diagnosis, Differential
Hemorrhage/diagnosis
Humans
*Killer Cells, Natural
Lymph Nodes/pathology
Lymphoma, T-Cell/*diagnosis/pathology
Male
*T-Lymphocytes
Tuberculosis, Endocrine/diagnosis

Figure

• 

  Fig. 1 Outside computed tomography (CT) scan of the abdomen and chest radiography taken at admission. (A) CT scan reveals the enlargement surrounding both adrenal glands, especially left side and hyperattenuating fat (arrows) which is suggesting inflammatory condition or hemorrhage. On the chest radiographys, blunting of left costophrenic angle (arrowhead) on the posteroanterior view (B) and fluid shifting (arrowheads) in the left decubitus view (C) demonstrate the presence of pleural fluid in left pleural space. There is no abnormal consolidative or mass-like lesion in both lung fields.

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  Fig. 2 Magnetic resonance imaging (MRI) of the abdomen. The enlargement surrounding both adrenal glands which is aggravated compared with the previous CT scan. The isosignal intensity on T1-weighted image (A) and subtle low signal intensity on T2-weighted image (B) around both adrenal glands suggest adrenal hemorrhage or adrenalitis such as adrenal tuberculosis.

• 

  Fig. 3 Follow up CT scan of the abdomen. (A) The enlargement surrounding both adrenal glands with low attenuation which is more aggravated and extended to the retroperitoneal space compared with the previous CT scan and MRI. (B) The enlargement of multiple paraaortic lymph nodes which are not evident in the previous CT scan are detected on this study.

• 

  Fig. 4 Positron emission tomography (PET)/CT scan. Variable intensities of FDG uptake is detected in both adrenal glands and surrounding retroperitoneal space, and in the cervical, mediastinal and paraaortic lymph nodes.

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  Fig. 5 Pathological finding of surgically excised cervical lymph node. (A) The lymph node is well capsulated with marked degree of necrosis (H&E, × 100), (B) Neoplastic infiltrate of relatively pleomorphic lymphoid cells with scanty cytoplasm, irregular nuclear contour, and prominent nucleoli (H&E, × 400). Immunohistochemical staining demonstrate positive nuclear staining with Ki-67 (MIB-1) (C), and positive for CD45 (D), CD30 (E) and CD56 (F), but negative CD20 activity (G).

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