Bilateral Adrenal Incidentalomas: A Case Report and Review of Diagnostic Challenges

Incidentally discovered adrenal masses (incidentalomas) are common and present challenges both in diagnosis and management. When incidentally discovered adrenal masses are bilateral, a refined diagnostic approach is warranted since bilateral disease is more likely to be pathologic. We review a case of a 34-year-old man with incidentally discovered bilateral adrenal nodules. A comprehensive diagnostic strategy led to the diagnosis of bilateral pheochromocytoma caused by von Hippel-Lindau syndrome. He was successfully treated with bilateral laparoscopic adrenalectomy and has recovered well. While the initial diagnostic approach is similar to the unilateral incidentaloma, additional testing and/or genetic testing should be considered in the case of the bilateral adrenal mass. 1. Introduction The incidentally found adrenal mass presents several complex management issues. Defined as a mass 1？cm or more in diameter found during a radiologic study done for reasons other than evaluation for adrenal disease, the adrenal “incidentaloma” is present in approximately 6% of the population [1]. The prevalence increases with age, with patients greater than 70 years old having a prevalence of 7%, compared to 0.2% for those age 20–29 [2]. Most are nonfunctional benign adenomas, and recently published guidelines address the optimal approach to these lesions [3]. However, the discovery of incidental bilateral adrenal masses requires special attention and an expanded diagnostic approach. 2. Case Presentation The patient is a 34-year-old, Caucasian male who was referred to our endocrinology clinic for evaluation of resistant hypertension. The patient had been experiencing chronic headaches and intermittent episodes of chest pressure for approximately 6 months. He denied other associated symptoms including flushing, diaphoresis, and palpitations. There was no family history of endocrine neoplasms or early cerebral or cardiovascular disease. We obtained a renal artery duplex to evaluate for renovascular disease due to patient’s young age and hypertension. The duplex demonstrated bilateral enlargement of the adrenal glands, and MRI of the abdomen showed high T2 intensity of bilateral adrenal masses with the right-sided mass measuring 4.3？cm and the left-sided mass measuring 2.8？cm (Figure 1). A 24-hour urine collection demonstrated a normetanephrine level of 9250？ug/24 hours (normal range 50–650？ug/24 hours). Plasma norepinephrine was also elevated at 3127？pg/mL (normal supine range 70–750？pg/mL) with a plasma normetanephrine of 23.1？nmol/L (normal < 0.90？nmol/L). Early morning