Bilateral primary adrenal lymphoma presenting with chylothorax: imaging findings and diagnostic challenges

Primary adrenal lymphoma is a rare and aggressive subtype of extranodal lymphoma with nonspecific clinical presentation. The coexistence of chylothorax and imaging findings suspicious for intratumoral hemorrhage in primary adrenal lymphoma is exceedingly rare and poorly understood. Herein, we report a case of bilateral primary adrenal diffuse large B-cell lymphoma (DLBCL) presenting with chylothorax secondary to lymphatic obstruction and imaging findings suspicious for intratumoral hemorrhage, highlighting the underlying pathophysiological mechanisms, multimodality imaging findings, and diagnostic challenges. A 67-year-old male patient presented with complaints of fever, night sweats, fatigue, and cough. Contrast-enhanced CT of the thorax and abdomen revealed pleural effusion in the left hemithorax. Thoracentesis was performed, and the patient was diagnosed with chylothorax. Concurrently, large bilateral adrenal masses with heterogeneous attenuation and focal hyperattenuating areas were identified. These hyperattenuating regions were considered suspicious for intratumoral hemorrhage. Subsequent PET/CT demonstrated intense hypermetabolic activity in both adrenal masses. An image-guided tru-cut biopsy was performed, and histopathological evaluation confirmed the diagnosis of diffuse large B-cell lymphoma. This case highlights that primary adrenal lymphoma may present with atypical manifestations such as chylothorax and imaging findings suspicious for intratumoral hemorrhage, emphasizing the importance of multimodality imaging, clinicopathological correlation, and consideration of this entity in the differential diagnosis of bilateral adrenal masses.