Endocrine Abstracts

We report the case of a 73-year-old Cypriot man with bilateral adrenal histoplasmosis. He had spent many years working in Southern Africa and had retired to Cyprus more than ten years ago. One year prior to diagnosis he underwent an elective cholecystectomy. Pre-operatively bilateral adrenal co-incidentalomas were noted on ultrasound and computed tomography (CT). Fine needle aspiration showed adipocytes within the gland and the patient had no further investigations at this time. A year later he became acutely unwell and was found to be hypoadrenal. He was subsequently referred to us for further investigation. A repeat CT scan showed that his adrenals had increased in size. He had an ultrasound-guided biopsy which again showed fatty tissue. We considered the diagnosis of bilateral myelolipomata to explain these findings but there was no reference in the literature to show an association with hypoadrenalism. Consequently, he had further imaging with a magnetic resonance scan which showed that the adrenals were heterogeneous and hence not consistent with complete fatty infiltration. A third biopsy was arranged under CT-guidance which again revealed predominantly adipose tissue. However, there was a central core of tissue showing diffuse infiltration of yeast forms. This was later confirmed to be Histoplasma capsulatum. The patient had no signs of disseminated histoplasmosis and serology was negative. He was treated with itraconazole and subsequently ketoconazole.

Histoplasmosis should be considered in the differential diagnosis of bilateral adrenal enlargement and Addison's disease, even in the absence of systemic symptoms and a relevant travel history.