Endocrine Abstracts

A 75 year old male presented in August 2017 with dizziness, nausea and weight loss. In ENT clinic he was found to have right vocal cord lesion. He had CT chest, abdomen and pelvis which showed mediastinal and hilar lymphadenopathy and bilateral adrenal lesions. A PET–CT scan showed intense metabolic uptake in the adrenals with low volume, but moderately active mediastinum and hilar lymphadenopathy. He was presumed to have adrenal and mediastinal Tuberculosis and was started on anti-tuberculosis medications. He had postural hypotension and moderate hyponatraemia and had Short Synacthen Test which sowed baseline cortisol of 364 but post tetracosactide cortisol inceased very mildly to 377 and 392 after 30 and 60 min respectively. He had further extensive investigations and adrenal biopsy showed necrotising granuloma which was negative for TB culture and PCR. Fungal stain suggested fungal spores (PAS stain positive for fungal spores, although cryptococcal Ag negative). Pan fungal PCR result from fungal reference lab was positive for Histoplasma Capsulata, and later culture was also positive for Histoplasma. He was started on treatment of disseminated Histoplasmosis with two weeks of IV ambisome, loaded on itraconazole, and then started on oral itraconazole. Keeping in view postural hypotension, hyponatraemia and flat response to Short Synacthen Test, hydrocortisone and fludrocortisone were started. Postural hypotension and hyponatraemia resolved and Fludrocortisone was withdrawn successfully. He had Short Synacthen Test after one year with baseline cortisol of 148, 30 min post tetracosactide cortisol 157 and 60 min cortisol was 161, indicative of permanent adrenal failure. CT chest, abdomen and pelvis repeated after 18 months of treatment which showed mild improvement in mediastinal lymphadenopathy but adrenal lesions significantly improved. Patient continues to be on Itraconazole and hydrocortisone and is clinically doing very well and is currently asymptomatic.