Endocrine Abstracts

Introduction: Extrapulmonary manifestations of tuberculosis can cause a diverse range of atypical presentations, depending on the system involved. Involvement of lymph nodes, pleura, central nervous system and bone are some of the organs that are well-described in the literature. This leads to a diverse range of presentations which can misguide diagnosis unless there is a high index of suspicion. Endocrinological manifestations are rare, but can occur uponhaematogenous dissemination of Mycobacterium tuberculosis in miliary tuberculosisto well-vascularised organs such as the adrenals, presenting with adrenal insufficiency or Addisonian crisis acutely.

Case description: We present the case of a 59-year-old man of South Asian origin, who presented in adrenal Addisonian crisis with a history of a significant, unintentional weight loss. He presented with classical signs of hyperpigmentation of the skin, hyponatraemia, hyperkalaemia and hypotension. A diagnosis of miliary tuberculosis was made based upon imaging, with suspected involvement of the adrenal glands. The patient improved with anti-tuberculosis chemotherapy and corticosteroid supplementation. The patient also later experienced tonic-clonic seizures and an altered personality, and magnetic resonance imaging later revealed several tuberculomas. The seizures were managed with levetiracetam, and corticosteroids were used to control tuberculoma development. Weaning of corticosteroids was necessary to conduct a short synacthen test. However, this repeatedly led to the patient being admitted on further occasions, presenting with similar signs of adrenal insufficiency. Eventually when a short synacthen test was conducted, it was able to demonstrate a lack of a cortisol response, which combined with high levels of adrenocorticotrophic hormone and bilaterally enlarged adrenals, suggested the patient was experiencing primary adrenal insufficiency secondary to extrapulmonary tuberculosis of the adrenals.

Discussion: The systemic manifestations of tuberculosis are complex, with little literature available regarding the involvement of adrenal glands. This case report describes the progression of possibly long-standing miliary tuberculosis to cerebral tuberculoma and adrenal tuberculosis, likely through lymphohaematogenous spread. Immunosuppressive therapies and the HIV/AIDS pandemic is likely to increase the incidence of unusually presenting extrapulmonary manifestations of tuberculosis. Therefore, it is important to acknowledge adrenal insufficiency and seizures as potential presentations of tuberculosis, particularly in the context of disseminated miliary tuberculosis.