Supplementary Material for: Primary Adrenal Lymphoma Presenting as Bilateral Adrenal Masses – Case Report

Background: Bilateral adrenal masses are increasingly detected in clinical practice. Primary adrenal lymphoma (PAL) is a rare type of non-Hodgkin’s lymphoma, usually presenting with bilateral adrenal involvement and, in some cases, with primary adrenal insufficiency (PAI). Due to its rarity and nonspecific presentation, PAL remains a diagnostic challenge. Case Presentation: We report the case of a 47-year-old female referred to the Endocrinology Clinic for bilateral adrenal masses. She presented with fever, asthenia, and hyperhidrosis but no signs of hormonal hypersecretion. Physical examination revealed cutaneous hyperpigmentation. Bloodwork showed no hormonal hypersecretion and confirmed PAI. An 18F-FDG-PET/CT showed glucose uptake in both adrenal masses, as well as in some lymphadenopathies. Additional laboratory findings included elevated β2-microglobulin, lactate dehydrogenase (LDH), and ferritin levels. An adrenal biopsy confirmed the diagnosis of diffuse large B-cell lymphoma. The patient underwent systemic treatment with radiological remission. However, adrenal function did not recover, and she maintains the need for glucocorticoid and mineralocorticoid replacement. Conclusion: This case highlights the need to consider PAL in the differential diagnosis of bilateral adrenal masses, particularly in patients with constitutional symptoms and adrenal insufficiency. Adrenal biopsy remains a valuable diagnostic tool in select cases and adrenal function recovery isn’t always possible.