Endocrine Abstracts

Introduction: Addison’s disease is a rare disorder, described mainly in isolated cases. The two most common cause of primary adrenal insufficiency are autoimmune adrenalitis and adrenal tuberculosis, which is still the primary cause of primary adrenal insufficiency (PAI) in developing countries. Adrenal tuberculosis is difficult to diagnose, the classic presentation with non specific symptoms delay the diagnosis. In some cases, the background of tuberculosis and hyperpigmentation, which is one of the most common clinical manifestation in Addison’s disease, allow early recognition.

Case 1: An 43-year-old male patient without a significant past medical history was investigated for a sudden onset of: nausea, vomiting, inappetence, and azotate retention. Examination showed remarkable hyperpigmentation of the skin, oral mucosa and nails. Biological test identified hyponatremia (129 mmol/l), hyperkalemia (5.43 mmol/l), high ACTH (>1250 pg/ml), low serum cortisol level (2.1 ug/dl), suggestive values for primary adrenal insufficiency. After glucocorticoids replacement,the electrolytes imbalances and his symptoms have improved significantly. Past exposure of the pacient to tuberculosis (2 years ago) and positive tuberculin skin test have established the etiology. Abdominal CT-scan detected two unomogenous nodular lesions (right adrenal gland – 26/30/49 mm, left adrenal gland – 36/19/54 mm), with peripheral calcifications suggestive for adrenal tuberculosis.

Case 2: An 63-year-old male patient was admitted in surgical department for important weight loss (30 kg in 12 months), weakness, nausea, fatigue and loss of appetite, mental confusion and dizziness. A chest and abdominal CT-scan revealed multiple mediastinal adenopathies and bilaterally enlarged adrenal glands with unomogenous nodular lesions (on the right – 16/13/22 mm, on the left – 50/38/47 mm) with diffuse calcifications and heterogeneous peripheral enhancement. Serum cortisol level was <1 ug/dl and serum ACTH was >1250 pg/ml, confirming primary adrenal insufficiency. Due to the suspicion of adrenal carcinoma patient underwent left adrenalectomy. Histopathological examination revealed typical granulomatous infllammation with Langhans giant cells and caseous necrosis, the tissue PCR test confirming the presence of Mycobacterium tuberculosis. Currently, both patients started on four-drug anti-tuberculosis therapy (isoniazid, rifampin, pyrazinamide and ethambutol) along with Hydrocortisone and Fludrocortisone supplementation.

Conclusions: Adrenal tuberculosis is rare but an important disease entity that must be identified early, requiring prompt treatment with antituberculosis drugs and appropiate steroid therapy. Sometimes the ultrasound image of the adrenal tuberculosis can cause confusion with adrenal carcinoma causing important problems of differential diagnosis and treatment.

Key words: Tuberculosis, Adrenal gland, PAI