Adrenal Insufficiency Secondary To Tuberculous Adrenalitis in a patient without active pulmonary tuberculosis and negative mycobacterial cultures, stains and PCR

Program: Abstracts - Orals, Featured Poster Presentations, and Posters
Session: SUN 1-16-Adrenal Insufficiency
Clinical
Sunday, June 16, 2013: 1:45 PM-3:45 PM
Expo Halls ABC (Moscone Center)

Poster Board SUN-8
Ali Alexandru Achira*, Dania Abushanab, Athar Haq, Hussein Elbadawi and Sorabh Dhar
Wayne State University, Detroit, MI
Adrenal Insufficiency Secondary To Tuberculous Adrenalitis Without Active Pulmonary Tuberculosis

 

Achira A Ali, Dhar Sorabh,Taha Wael, Abushanab Dania, Elbadawi Hussein,Haq Athar.

 

Introduction

  Adrenal Tuberculosis is seen in 6% of patients with active pulmonary tuberculosis.  Clinical manifestations of Addison disease are seen in only 12% of patients who have active adrenal Tuberculosis and occur when 90% of the adrenal tissue is destroyed by the infection.

 

The Case

38 year old African man from Uganda, with no significant past medical history, presented with nausea, vomiting, weakness and decreased appetite for 4 months with a weight loss of 20 pounds.

Examination revealed BP of (94/65mmHg), orthostatic hypotension, and skin hyperpigmentation. Laboratory studies showed a serum sodium of 125 mmol/L, potassium of 6.2 mmol/L, and am cortisol level of 2 mcg/dL. Cosyntropin stimulation test was done; cortisol was 1.8 at 0 min and 1.9 at 60 min. Morning ACTH level was 655 pg/mL (7-69 pg/ml).

The diagnosis of primary adrenal insufficiency was made, and  patient was started on Hydrocortisone. Further investigations revealed a positive PPD test (22 x28 mm induration). TB Quantiferon Gold test was >10 IU/ml (Reference range ≤0.34 IU/ml). High resolution CT chest showed nonspecific 5 mm nodule in the right upper lung lobe with mild right hilar adenopathy (suggesting Gohn complex). Three mycobacterial sputum stains and cultures were negative for acid fast bacilli. CT scan of the abdomen and pelvis showed diffusely enlarged adrenal glands with a 5.8cm bi-lobed, mildly enhancing mass in the left adrenal gland.

Biopsy of the left adrenal mass showed chronic inflammation with Langerhan’s giant cells. No normal adrenal tissue could be identified. Mycobacterial culture and stain for Acid Fast Bacilli were negative after >8 weeks, and Mycobacterium TB PCR on tissue biopsy was negative.

Other negative tests were HIV 1 /2 Antibody (EIA), Rapid Plasma Reagin, fungal antibodies, fungal cultures of the adrenal gland and adrenal antibodies.

Discussion

Most cases of adrenal tuberculosis are found 10 to 15 years after the initial infection; hence, tuberculous Addison’s disease has a relatively late onset and delayed diagnosis. The characteristic granuloma, can be soft exudative (frequently have acid fast bacilli) or Hard granuloma (frequently have no acid fast bacilli). Thus, a negative Mycobacterium culture and TB PCR does not rule out tuberculous adrenalitis.

In our patient, anti-tuberculosis therapy was initiated. However, recovery of adrenal function is atypical.

Conclusion :

A presumptive clinical diagnosis of adrenal tuberculosis (based on epidemiologic exposure, physical findings, radiographic findings, positive tuberculin skin test and/or histopathology) is sufficient for initiating therapy. A negative mycobacterial culture , stain and tuberculosis PCR does not exclude a diagnosis of tuberculosis.

Nothing to Disclose: AAA, DA, AH, HE, SD

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