Differences in Glycemic Control for Inpatients with Type 1 Diabetes on Insulin Pump Versus Subcutaneous Insulin Therapy.

BACKGROUND: Inpatient use of insulin pump therapy has been increasing due to greater availability of this technology, however there is a paucity of research that investigates glycemic control of inpatient insulin pump users. OBJECTIVE: To compare the glycemic control of hospitalized patients with type 1 diabetes (T1D) who used insulin pump vs. multiple daily injections (MDI). DESIGN: Retrospective chart review. PARTICIPANTS: Patients with T1D who were hospitalized between January 1, 2017, and December 31, 2019, in an academic medical center in the New York metropolitan area. MAIN MEASURES: Patients were categorized into three groups based on their method of insulin administration: "pump only" group used insulin pump exclusively, "MDI only" group used MDI only, and "intermittent pump" group used a combination of both methods. The primary endpoints are mean blood glucose, rates of hypoglycemic events (blood glucose < 70 mg/dL), and rates of hyperglycemic events (blood glucose > 250 mg/dL). Separate multivariable Poisson regressions were performed to determine the association between the type of insulin administration and rate outcomes (i.e., rate of hypoglycemic events and rate of hyperglycemic events). RESULTS: The study included 78 patients with a mean age of 51, who were mostly male (54%), and white (72%). The average proportion of glucose measurements that were hyperglycemic for the "pump only", "MDI only", and "intermittent pump" groups were 0.11 (SD = 0.11), 0.25 (SD = 0.19), and 0.24 (SD = 0.25), respectively. The "pump only" group has a significantly lower proportion of hyperglycemic events as compared to the "MDI only" group (p = 0.0227). CONCLUSIONS: In this sample, patients who exclusively used their insulin pump while inpatient had a lower rate of hyperglycemic events than patients who used MDI only; suggesting that select patients can safely continue their insulin pump therapy in the inpatient setting.

The Risk of and Associated Demographic and Laboratory Variables for Amputations for Inpatients with Diabetic Foot Ulcers.

OBJECTIVE: Diabetic foot ulcers (DFUs) are a leading cause of morbidity and mortality, which disproportionately impacts underserved populations. This study aimed to provide data regarding the rates and outcomes of amputation in patients admitted with DFU in our health system, which cares for an ethnically diverse and underserved population. METHODS: This retrospective study examined the electronic medical records of adult patients hospitalized with DFU at 3 hospitals in our health system between June 1, 2016, and May 31, 2021. RESULTS: Among 650 patients admitted with DFU, 88% self-identified as non-White race. Male sex (odds ratio [OR], 0.62), low body mass index (OR, 0.98), and history of smoking (OR, 1.45) were significantly associated with amputation during the study period. A higher erythrocyte sedimentation rate (OR, 1.01), C-reactive protein level (OR, 1.05), and white blood cell count (OR, 1.11) and low albumin level (OR, 0.41) were found to be significantly associated with amputation versus no amputation during admission. The amputation risk during the index admission for DFU was 44%. CONCLUSION: Our study identified a high DFU-related amputation risk (44%) among adult patients who were mostly Black and/or Hispanic. The significant risk factors associated with DFU amputation included male sex, low body mass index, smoking, and high levels inflammation or low levels of albumin during admission. Many of these patients required multidisciplinary care and intravenous antibiotic therapy, necessitating a longer length of stay and high readmission rate.

Demographic Variables Associated With Diabetes Technology Awareness or Use in Adults With Type 2 Diabetes.

Background: Studies in populations with type 1 diabetes highlight racial/ethnic disparities in the use of diabetes technology; however, little is known about disparities among those with type 2 diabetes. This project investigates the racial/ethnic and socioeconomic disparities in diabetes technology awareness and use in adults with type 2 diabetes in the ambulatory setting. Methods: Adults ≥40 years of age with type 2 diabetes in ambulatory care were invited to participate via an e-mail link to a de-identified REDCap (Research Electronic Data Capture) questionnaire. Variables, including awareness and use of continuous glucose monitoring (CGM) and insulin pumps, were summarized descriptively using frequencies and percentages and were compared across racial/ethnic groups, education level, and income using Pearson χ2 or Fisher exact tests. Results: The study included 116 participants, most of whom (62%) were White, elderly Medicare recipients. Compared with White participants, those of racially/ethnically minoritized groups were less likely to be aware of CGM (P = 0.013) or insulin pumps (P = 0.001). Participants with a high school education or less were also less likely to be aware of insulin pumps (P = 0.041). Interestingly, neither awareness nor use of CGM or insulin pumps was found to be associated with income. Conclusion: This cross-sectional analysis suggests that racially/ethnically minoritized groups and individuals with lower education have less awareness of CGM or insulin pumps.

Associations of microvascular complications with all-cause death in patients with diabetes and COVID-19: The CORONADO, ABCD COVID-19 UK national audit and AMERICADO study groups.

AIM: To provide a detailled analysis of the microvascular burden in patients with diabetes hopitalized for COVD-19. MATERIALS AND METHODS: We analysed data from the French CORONADO initiative and the UK Association of British Clinical Diabetologists (ABCD) COVID-19 audit, two nationwide multicentre studies, and the AMERICADO, a multicentre study conducted in New York area. We assessed the association between risk of all-cause death during hospital stay and the following microvascular complications in patients with diabetes hospitalized for COVID-19: diabetic retinopathy and/or diabetic kidney disease and/or history of diabetic foot ulcer. RESULTS: Among 2951 CORONADO, 3387 ABCD COVID-19 audit and 9327 AMERICADO participants, microvascular diabetic complications status was ascertained for 1314 (44.5%), 1809 (53.4%) and 7367 (79.0%) patients, respectively: 1010, 1059 and 1800, respectively, had ≥1 severe microvascular complication(s) and 304, 750 and 5567, respectively, were free of any complications. The patients with isolated diabetic kidney disease had an increased risk of all-cause death during hospital stay: odds ratio [OR] 2.53 (95% confidence interval [CI] 1.66-3.83), OR 1.24 (95% CI 1.00-1.56) and OR 1.66 (95% CI 1.40-1.95) in the CORONADO, the ABCD COVID-19 national audit and the AMERICADO studies, respectively. After adjustment for age, sex, hypertension and cardiovascular disease (CVD), compared to those without microvascular complications, patients with microvascular complications had an increased risk of all-cause death during hospital stay in the CORONADO, the ABCD COVID-19 diabetes national audit and the AMERICADO studies: adjusted OR (adj OR) 2.57 (95% CI 1.69-3.92), adj OR 1.22 (95% CI 1.00-1.52) and adj OR 1.33 (95% CI 1.15-1.53), respectively. In meta-analysis of the three studies, compared to patients free of complications, those with microvascular complications had an unadjusted OR for all-cause death during hospital stay of 2.05 (95% CI 1.42-2.97), which decreased to 1.62 (95% CI 1.19-2.119) after adjustment for age and sex, and to 1.50 (1.12-2.02) after hypertension and CVD were further added to the model. CONCLUSION: Microvascular burden is associated with an increased risk of death in patients hospitalized for COVID-19.

Racial and Ethnic Disparities in Diabetes Clinical Care and Management: A Narrative Review.

Diabetes affects nearly 37 million Americans, with disproportionately higher disease burden amongst those from minoritized communities. The result of this is greater rates of diabetic complications and mortality. To close this gap in care, it is important to assess the differences in both diagnosis and care between White and ethnic/racial minoritized persons with diabetes. The purpose of this narrative review is to explore this further by assessing the differences in diagnosis, management, diabetes education, and complications.

The Use of Diabetes Technology to Address Inequity in Health Outcomes: Limitations and Opportunities.

PURPOSE OF REVIEW: The management of diabetes has been revolutionized by the introduction of novel technological treatments and modalities of care, such as continuous glucose monitoring, insulin pump therapy, and telehealth. While these technologies have demonstrated improvement in health outcomes, it remains unclear whether they have reduced inequities from racial/ethnic minority or socioeconomic status. We review the current literature to discuss evidence of benefit, current limitations, and future opportunities of diabetes technologies. FINDINGS: While there is ample evidence of the health and psychological benefit of diabetes technologies in large populations of people with type 1 and type 2 diabetes, there remain wide disparities in the use of diabetes technologies, which may be perpetuating or widening inequities. Multilevel barriers include inequitable prescribing practices, lack of support for social determinants of health, mismatch of patient preferences and care models, and cost. We provide a review of disparities in diabetes technology use, possible root causes of continued inequity in outcomes, and insight into ways to overcome remaining gaps.

COVID-19 Conversations Within Black/Brown Minority Communities: A Stakeholder and Psychoeducation Approach Using Zoom/Facebook Live.

As communities of color are disproportionately affected by COVID-19, there is an urgent need for dissemination of timely and accurate information to community members. In this article, we describe a stakeholder approach for the implementation, evaluation, and lessons learned from COVID-19 Conversations, a program developed and delivered virtually by researchers and academics at Northwell Health. The goal of the program was to address the mental, physical, and psychosocial needs of community members. The program used Zoom/Facebook Live to deliver interactive discussions on topics ranging from health education on COVID-19 and mental health to resources for unmet social needs. This interprofessional, cross-sector collaboration highlights the importance of public health interventions aimed at reducing the spread of COVID-19 through easy online access and culturally relevant community education and outreach.

Implementation of a Weight-Based Protocol for the Management of Steroid-Induced Hyperglycemia.

BACKGROUND: Hyperglycemia is a recognized complication of supraphysiological steroid dosing. There are no consensus guidelines on optimal treatment of steroid-induced hyperglycemia. We assessed the safety of a weight-based insulin protocol for persons treated with supraphysiological doses of steroids to examine the efficacy of using this protocol in patients with diabetes treated with prednisone or methylprednisolone. AREAS OF UNCERTAINTY: There is uncertainty about the optimal dosing of insulin to manage steroid-induced hyperglycemia; thus, a weight-based protocol was created with the goal of reaching euglycemia faster than current practice in persons with diabetes. Variables such as steroid dosing, baseline glycemic control, and duration of steroid use further complicated the ability to manage these patients. INNOVATIONS: The interdisciplinary team of diabetes providers and pharmacists worked together to devise a protocol to manage steroid-induced hyperglycemia with the goal of reducing hyperglycemia while avoiding hypoglycemia, as well as to allow for less reliance on endocrine consultation. The protocol used weight, insulin naivety, renal function, blood glucose measurements, and steroid dosing to determine the insulin dose. There was some evidence to suggest the proportion of blood glucose levels more than 200 mg/dL was lower after protocol initiation compared with before protocol initiation (P = 0.053). Several factors decreased the rate of successful outcomes, including minimal primary team participation, accurate completion of calculations based on the protocol, and initiation of the protocol after several days of hyperglycemia.

Identifying the barriers and perceptions of non-Hispanic black and Hispanic/Latino persons with uncontrolled type 2 diabetes for participation in a home Telemonitoring feasibility study: a quantitative analysis of those who declined participation, withdrew or were non-adherent.

Objectives: Type 2 Diabetes Mellitus and its complications disproportionately affect non-Hispanic blacks and Hispanic/Latinos more than non-Hispanic whites. These disparities stem from complex interactions between biological, behavioral and socioeconomic factors. In recent years, telemedicine has been used to manage Type 2 Diabetes; however limited recruitment and retention of black and Hispanic/Latino patients into clinical trials exploring the use of telemedicine have necessitated the elucidation of their perceptions regarding participation in such trials. This study investigated patient-reported reasons for declining participation, prematurely terminating participation or demonstrating poor adherence to the study protocol in an ongoing randomized clinical trial, 'Feasibility of Telehealth Management of Diabetes Mellitus type 2 (T2DM) in Black and Hispanic Minority Patients'.Design: Semi-structured interviews comprised of open-ended questions and prompts were conducted by telephone to gauge patients' actual and perceived challenges to participating in the trial and using telemedicine to manage their diabetes. Data were collated with that of the original clinical trial and subsequently content analyzed for overarching themes and trends.Results: Eight semi-structured interviews were completed telephonically. Themes that emerged from analysis included disinterest (47%), inconvenience (33%), lack of perceived benefit (13%), lack of awareness of diabetes diagnosis (7%) and perceived lack of ability to fully participate in the study (7%).Conclusion: Adoption of telemedicine to help minority patients manage diabetes holds promise but is limited by patient factors such as disinterest, inconvenience and lack of perceived benefit. Greater awareness and understanding of these issues will be critical as we strive for greater health equity in disparity patients with uncontrolled diabetes.

Adapting a home telemonitoring intervention for underserved Hispanic/Latino patients with type 2 diabetes: an acceptability and feasibility study.

BACKGROUND: Home telemonitoring is a promising approach to optimizing outcomes for patients with Type 2 Diabetes; however, this care strategy has not been adapted for use with understudied and underserved Hispanic/Latinos (H/L) patients with Type 2 Diabetes. METHODS: A formative, Community-Based Participatory Research approach was used to adapt a home telemonitoring intervention to facilitate acceptability and feasibility for vulnerable H/L patients. Utilizing the ADAPT-ITT framework, key stakeholders were engaged over an 8-month iterative process using a combination of strategies, including focus groups and structured interviews. Nine Community Advisory Board, Patient Advisory, and Provider Panel Committee focus group discussions were conducted, in English and Spanish, to garner stakeholder input before intervention implementation. Focus groups and structured interviews were also conducted with 12 patients enrolled in a 1-month pilot study, to obtain feedback from patients in the home to further adapt the intervention. Focus groups and structured interviews were approximately 2 hours and 30 min, respectively. All focus groups and structured interviews were audio-recorded and professionally transcribed. Structural coding was used to mark responses to topical questions in the moderator and interview guides. RESULTS: Two major themes emerged from qualitative analyses of Community Advisory Board/subcommittee focus group data. The first major theme involved intervention components to maximize acceptance/usability. Subthemes included tablet screens (e.g., privacy/identity concerns; enlarging font sizes; lighter tablet to facilitate portability); cultural incongruence (e.g., language translation/literacy, foods, actors "who look like me"); nursing staff (e.g., ensuring accessibility; appointment flexibility); and, educational videos (e.g., the importance of information repetition). A second major theme involved suggested changes to the randomized control trial study structure to maximize participation, including a major restructuring of the consenting process and changes designed to optimize recruitment strategies. Themes from pilot participant focus group/structured interviews were similar to those of the Community Advisory Board such as the need to address and simplify a burdensome consenting process, the importance of assuring privacy, and an accessible, culturally congruent nurse. CONCLUSIONS: These findings identify important adaptation recommendations from the stakeholder and potential user perspective that should be considered when implementing home telemonitoring for underserved patients with Type 2 Diabetes. TRIAL REGISTRATION: NCT03960424; ClinicalTrials.gov (US National Institutes of Health). Registered 23 May 2019. Registered prior to data collection. https://www.clinicaltrials.gov/ct2/show/NCT03960424?term=NCT03960424&draw=2&rank=1.

Sleep and Environmental Factors Affecting Glycemic Control in People with Type 2 Diabetes Mellitus.

PURPOSE OF REVIEW: Sleep and environmental factors both impact glycemic control in persons with type 2 diabetes mellitus (T2DM). This narrative article aims to review research within the past 5 years, focusing on chronotype, light, noise, and neighborhood disparities in relation to sleep in people with T2DM. RECENT FINDINGS: Sleep quality and duration have been shown to impact glycemic control in patients with T2DM. Later chronotype can lead to poorer glycemic control due to disruption of circadian rhythms. Light exposure also has similar effects, likely due to its inherent influence on sleep quality. Environmental determinants, were associated with lower T2DM incidence, and noise and air pollution were associated with increased risks for T2DM. Findings were mixed; while most studies found that later chronotype, light/noise exposure, and neighborhood disadvantages were associated with poorer glycemic control in patients with T2DM, other environmental factors, such as green space, were not significantly associated with diabetes outcomes.

Relationship between obesity and depression: characteristics and treatment outcomes with antidepressant medication.

OBJECTIVE: Obesity and major depressive disorder often co-occur. However, differences between obese and normal-weight depressed patients and the moderating effect of obesity on antidepressant treatment outcome are not well studied. METHODS: Adults (n = 662) with major depressive disorder in the Combining Medications to Enhance Depression Outcomes study were randomized to treatment with escitalopram plus placebo, bupropion plus escitalopram, or venlafaxine plus mirtazapine for a 12-week primary treatment phase and 16-week follow-up. Body mass index (BMI) was calculated at baseline and categorized according to World Health Organization criteria: normal or low weight (NW), overweight, Obese I and Obese II+. A repeated-effects model, unadjusted and adjusted for baseline variables, assessed outcomes. RESULTS: Obesity was common (46.2%), only 25.5% were NW. Higher BMI was associated with greater medical illness (p < .001), social phobia (p = .003), and bulimia (p = .026). Lower BMI was associated with more frequent post-traumatic stress disorder (p = .002) and drug abuse (p < .001). Treatment outcomes did not differ including Week 12 remission rates (NW 36%, overweight 40%, Obese I 43%, Obese II+ 37%; p = .69). Lower BMI was associated with more frequent (p = .024 [unadjusted] and .053 [adjusted]) and more severe (p = .008 [unadjusted] and .053 [adjusted]) adverse effects. CONCLUSIONS: BMI was related to clinical presentation and prevalence of comorbidities, but not antidepressant outcomes. Lower BMI classes had more psychiatric comorbidities, potentially obscuring the relationship between BMI and antidepressant effects. Trial Registration ClinicalTrials.gov identifier: NCT00590863.

Intersectionality and Its Impact on Microaggression in Female Physicians in Academic Medicine: A Cross-Sectional Study.

Introduction: The burden of microaggressions in the workplace is an ongoing stressor for female physicians in academic medicine. For female physicians of Color or of the Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual community, this burden is even heavier due to the concept of intersectionality. The goal of this study is to assess frequency of microaggressions experienced by participants. In addition, to explore the associations between microaggression and individual outcomes, patient care practices and attitudes, and perception of pay/promotion equity. Methods: This was a cross-sectional analysis of female residents, fellows and attendings conducted from December 2020-January 2021 at Northwell Health across all specialties. One hundred seventeen participants replied to the study in REDCap. They completed questionnaires related to the topics of imposter phenomenon, microaggressions, gender identity salience, patient safety, patient care, counterproductive work behavior and pay and promotion equity. Results: A majority of the respondents were white (49.6%) and 15+ years out of medical school (43.6%). Around 84.6% of female physicians endorsed experiencing microaggressions. There were positive associations between microaggressions and imposter phenomenon as well as microaggressions and counterproductive work behavior. There was a negative association between microaggressions and pay equity or promotion. The small sample size did not allow for us to examine differences by race. Discussion: Although the number of female physicians continues to rise due to an uptick in female medical school enrollees, female physicians still must deal with the burden of microaggressions in the workplace. Conclusions: As a result, academic medical institutions must seek to create more supportive workplace for female physicians.

Black Physicians' Experiences with Anti-Black Racism in Healthcare Systems Explored Through An Attraction-Selection-Attrition Lens.

Anti-Black racism is a specific form of racism directed at Black people. In healthcare, there are poignant examples of anti-Black racism in the recruitment, selection, and retention stages of the job cycle. Research shows that anti-Black racism is associated with inequitable work outcomes and the under-representation of Black physicians. However, empirical findings are scattered with no organizing framework to consolidate these findings. To add to the literature, in this paper we present the attraction-selection-attrition (ASA) model (Schneider, 1987) as an organizing framework to discuss Black physicians' experiences with anti-Black racism and discrimination throughout their careers. We draw from previous literature to highlight specific experiences of Black physicians at each stage of the job cycle (i.e., attraction, selection, retention), and we offer considerations on how practitioners can mitigate anti-Black racism throughout the job cycle. In the wake of COVID-19 and highly publicized social justice movements, healthcare systems are seeking ways to increase the recruitment, selection, and retention of Black physicians to ensure health equity. We believe this guide will be valuable to practitioners, leaders, researchers, and program directions seeking to advance diversity, equity, and inclusion of Black physicians in their healthcare systems. We conclude by providing practical implications and directions for future research.

Continuous glucose monitors and virtual care in high-risk, racial and ethnic minority populations: Toward promoting health equity.

Continuous glucose monitors (CGMs) have become an important tool to aid self-management of blood glucose for many patients with diabetes in the U.S., and the benefits of CGM use are well-documented. However, disparities in CGM use exist, with lower use in certain marginalized racial and ethnic groups. CGM may be an important and underutilized tool to help reduce inequities. Evidence supporting the use of CGMs as a part of virtual care is discussed, with an emphasis on designing virtual diabetes care programs to promote health equity. Recommendations for clinical practice and research are presented. In clinical practice, CGM should be an option for all people with diabetes who qualify based on clinical practice guidelines, regardless of race, ethnicity, or other individual characteristics. Future research should characterize the use of, benefit from, and preferences for CGM among individuals from racial and ethnic groups to guide interventions at the health system, clinic, provider, and patient levels to promote equitable, evidence-based, and guideline-directed CGM use in marginalized racial and ethnic groups with diabetes.

COVID-19 stressors for Hispanic/Latino patients living with type 2 diabetes: a qualitative study.

Background and aim: During the early stages of the COVID-19 pandemic, nationwide lockdowns caused disruption in the diets, physical activities, and lifestyles of patients with type 2 diabetes. Previous reports on the possible association between race/ethnicity, COVID-19, and mortality have shown that Hispanic/Latino patients with type 2 diabetes who are socioeconomically disadvantaged are disproportionately affected by this novel virus. The aim of this study was to explore stressors associated with changes in diabetes self-management behaviors. Our goal was to highlight the health disparities in these vulnerable racial/ethnic minority communities and underscore the need for effective interventions. Methods and participants: Participants were enrolled in part of a larger randomized controlled trial to compare diabetes telehealth management (DTM) with comprehensive outpatient management (COM) in terms of critical patient-centered outcomes among Hispanic/Latino patients with type 2 diabetes. We conducted a thematic analysis using patient notes collected from two research nurses between March 2020 and March 2021. Two authors read through the transcripts independently to identify overarching themes. Once the themes had been identified, both authors convened to compare themes and ensure that similar themes were identified within the transcripts. Any discrepancies were discussed by the larger study team until a consensus was reached. Results: Six themes emerged, each of which can be categorized as either a source or an outcome of stress. Sources of stress associated with the COVID-19 pandemic were (1) fear of contracting COVID-19, (2) disruptions from lockdowns, and (3) financial stressors (e.g., loss of income). Outcomes of COVID-19 stressors were (1) reduced diabetes management (e.g., reduced diabetes monitoring and physical activity), (2) suboptimal mental health outcomes (e.g., anxiety and depression), and (3) outcomes of financial stressors. Conclusion: The findings indicated that underserved Hispanic/Latino patients with type 2 diabetes encountered a number of stressors that led to the deterioration of diabetes self-management behaviors during the pandemic.

Predictors of mortality in a multiracial urban cohort of persons with type 2 diabetes and novel coronavirus 19.

BACKGROUND: Diabetes has been identified as a risk factor for intubation and mortality in patients with coronavirus disease 2019 (COVID-19), caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We seek to examine the impact of clinical variables such as glycosylated hemoglobin (HbA1c) on mortality and need for intubation, as well as demographic variables such as age, sex, and race on persons with type 2 diabetes and COVID-19. METHODS: Analyses were conducted on 4413 patients with an International Classification of Diseases and Related Health Problems (ICD-10) diagnosis of type 2 diabetes and COVID-19. Survival analysis was conducted using Kaplan-Meier curves and the log-rank test to compare subgroup analyses. RESULTS: In this multivariate analysis, male gender, older age, and hyperglycemia at admission were associated with increased mortality and intubation, but this was not seen for race, ethnicity, insurance type, or HbA1c. Based on Kaplan-Meier analysis, having comorbid conditions such as hypertension, chronic kidney disease, and coronary artery disease was associated with a statistically significant increased risk of mortality. CONCLUSIONS: Glycemic levels at admission have a greater impact on health outcomes than HbA1c. Older men and those with comorbid disease are also at greater risk for mortality. Further longitudinal studies need to be done to evaluate the impact of COVID-19 on type 2 diabetes.

Suspected Primary Adrenal Lymphoma (PAL) Associated With Hemophagocytic Lymphohistiocytosis (HLH).

Adrenal incidentalomas, masses noted on imaging performed for other purposes, are common, with 10% to 15% presenting as bilateral adrenal masses. These cases can be challenging as the differential diagnosis is broad, including metastatic disease, primary adrenal lymphoma (PAL), or infection, and often requiring a biopsy if initial biochemical workup is unrevealing. We present here a relevant case description, laboratory and radiologic imaging studies, and discussion of literature. A 62-year-old Korean woman presented with altered mental status and fevers. She was found to have bilateral adrenal incidentalomas and retained acupuncture needles. Adrenal workup did not show biochemical evidence of hormonal excess. Infectious workup was unrevealing, as was a metal/toxin workup due to retained acupuncture needles. Fevers and episodes of hypotension persisted which prevented the patient from obtaining an adrenal biopsy. Bone marrow biopsy was obtained for pancytopenia and revealed B-cell lymphoma with large cell morphology and few histiocytes with hemophagocytosis, raising concern for lymphoma-induced hemophagocytic lymphohistiocytosis (HLH). PAL associated with HLH was highly suspected in our patient, given the large (7 cm) bilateral adrenal masses and bone marrow biopsy findings of lymphoma. The patient was treated for diffuse large B-cell lymphoma, with clinical improvement. PAL is a rare but aggressive lymphoma with few reported cases. It should be considered in the differential for both unilateral and bilateral adrenal masses. An early diagnosis is crucial as the main treatment is chemotherapy rather than surgery and it confers a significant survival benefit.