Unusual case of bilateral adrenal masses in Hong Kong

Abstract

In May 1996, a 56-year-old man in Hong Kong presented with fever and dry cough and had miliary shadows in bilateral lung fields on chest radiographs. The patient had migrated from Shanghai more than 10 years previously and worked as a cook. Upon admission, he was also found to have diabetes with poor glycaemic control. The clinical diagnosis was miliary tuberculosis (TB), however, all mycobacterial cultures were negative. The man was put on empirical anti-tuberculosis medication. Thrombocytopenia developed shortly afterwards. Bone marrow biopsy revealed foci of epithelioid cell granuloma and normal haematopoiesis, consistent with tuberculosis. Four months later, he presented with persistent bilateral epididymal masses with scrotal pain for 2 weeks. Tender and hardened epididymes were found upon physical examination. The clinical diagnosis was TB epididymitis. Mycobacterial culture of his early morning urine was negative. The empirical anti-TB treatment was lengthened to a total of 18 months until November 1997. In 1998, an incidental finding of bilateral adrenal masses was noted upon computed tomography (CT) of his abdomen. These masses were of soft tissue consistency density with no contrast enhancement in early and delayed phases. CT-guided fine needle aspiration of the right adrenal mass revealed necrotic tissue only in two successive examinations. Ziehl–Neelsen (ZN) stain was negative. Follow-up CT scans indicated no significant interval change in the size of the masses. In 2002, the man complained of insidious onset of left shoulder pain and swelling, as well as knee pain. Magnetic resonance imaging (MRI) and arthroscopy of the left shoulder were performed. MRI revealed rice bodies distending the joint capsule, especially over the subcoracoid and subdeltoid bursae. The clinical diagnosis was TB arthritis and osteomyelitis. Histology of the synovectomy specimen showed oedematous tissue with moderate chronic inflammation and a small focus of granulomatous inflammation. Neither caseous necrosis nor multinucleated giant cell was noted. ZN stain was again negative. The bacterial and mycobacterial cultures of the left shoulder synovial tissue and left knee aspirate were negative. No anti-TB treatment was prescribed. In January 2004, the man presented with significant weight loss. Workup revealed elevated alpha-fetoprotein. A liver tumour was detected, measuring 60640630 mm in greatest dimension and occupying the right lobe of liver, associated with unresolved bilateral adrenal enlargement. A short Synacthen test confirmed normal hypothalamic-pituitary-adrenal function. Partial hepatectomy (central), right adrenalectomy and cholescystectomy were performed. The right adrenal gland measured 55635618 mm in size and weighed 15 g. Serial sectioning showed a nodule with necrotic yellowish material (Fig. 1). Figures 2A and B show the H&E and Grocott stains of the sections of the adrenal lesion, respectively.