# Unexplained Bilateral Adrenal Hemorrhage and Adrenal Insufficiency Unveiling Burkitt's Lymphoma

## TL;DR

A rare case of adrenal hemorrhage and insufficiency was found to be caused by Burkitt's lymphoma, highlighting the need to consider cancer in such unexplained conditions.

## Contribution

This is the first reported case linking Burkitt's lymphoma to adrenal hemorrhage and insufficiency without typical risk factors.

## Key findings

- Burkitt's lymphoma can present with adrenal hemorrhage and insufficiency as initial symptoms.
- Diagnosis was confirmed through biopsy showing characteristic 'starry sky' pattern and CD20 positivity.
- Intensive chemotherapy led to significant clinical improvement in the patient.

## Abstract

Adrenal hemorrhage (AH) and adrenal insufficiency (AI) are rare, life-threatening conditions, typically linked to trauma, sepsis, or anticoagulation. Burkitt's lymphoma (BL), an aggressive B-cell non-Hodgkin lymphoma, rarely involves the adrenal glands and has not been reported to present with AH and AI. This report describes a unique case of AH and AI presenting as manifestations of BL, highlighting the importance of considering malignancy in unexplained AH and AI.

A 16-year-old boy presented with acute right flank pain and muscle spasms. Imaging revealed a right suprarenal hematoma with active contrast extravasation, managed with adrenal artery embolization. Two weeks later, he developed recurrent abdominal pain, vomiting, and distention. Computed tomography showed bilateral adrenal enlargement with necrosis and hemorrhage. Laboratory test results revealed normocytic anemia, increased lactate dehydrogenase level, and hypoglycemia. AI was confirmed (serum cortisol level, 1.5 μg/dL; adrenocorticotropic hormone level, 82 pg/mL), prompting hydrocortisone replacement. Positron emission tomography/computed tomography revealed hypermetabolic lesions in bilateral adrenal glands, lymph nodes, pleura, peritoneum, and bone marrow. Neck lymph node biopsy confirmed BL, showing a “starry sky” pattern, CD20 positivity, and Ki-67 nearing 100%. Intensive chemotherapy led to significant clinical improvement.

This case highlights the diagnostic challenge of AH and AI without typical risk factors. BL, although rarely involving the adrenal glands, should be considered in unexplained AH.

This report highlights the importance of considering malignancy in unexplained AH and AI, even without conventional risk factors.