Endocrine Abstracts

Background: Histoplasmosis is an opportunistic fungal infection that commonly affects immunocompromised individuals. Histoplasmosis may be asymptomatic or may present with progressive systemic manifestations (pulmonary or disseminated). We present a case of a 76 year old immunocompetent man presented to hospital with 8 weeks history of general malaise and lethargy, intermittent night sweats, a productive cough, weight loss of 2.5 stones in two months and low grade fever. He had completed two courses of antibiotics with no resolution of his symptoms. He reported no history of tuberculosis contacts. Significant history was of travel to Malaysia and a visit to bat caves 2 years prior to the onset of symptoms. On admission, he was haemodynamically stable and his initial blood tests were normal apart from raised CRP of 80 mg/l. Chest XRay was normal.CT of sinuses showed minimal mucosal thickening. CT chest, abdomen and pelvis revealed large bilateral adrenal heterogeneous masses measuring 6.1×4.5×3.7 cm on the right, and 6.4×6.2×4.3 cm on the left. Adrenal biopsy showed fungal spores on microscopy. He was started on antifungal therapy for likely adrenal histoplasmosis and discharged home. He was readmitted 2 months later with a GCS of 6/15, Temperature 38 °C, and hypotensive episodes. He had normal CT and MRI brain results, negative blood cultures and unremarkable CSF studies. Echocardiogram excluded the vegetations. He was treated with intravenous empirical antibiotics and hydrocortisone. He was continued on his antifungal therapy. Initial short synacthen test showed normal response, however he became more tired and hyperpigmented with a subsequent short synacthen test showing a suboptimal response T 0=333 nmol/l, T 30=378 nmol/l. He also developed primary hypogonadism subsequently, thought to be due to effect of antifungals or due to histoplasmosis itself. ConclusionAdrenal histoplasmosis is rare, especially in immunocompetent individuals and should be considered as a differential diagnosis in any patient presenting with bilateral adrenal masses, constitutional symptoms and suggestive history. Also one should be vigilant about possible side effects of antifungals e.g. hypogonadism in this case.