Endocrine Abstracts

Background: Multifocal tuberculosis is defined as the involvement of at least two extra-pulmonary sites, with or without pulmonary involvement. The most commonly involved endocrine organ is the adrenal gland. We report a case of adrenal insufficiency revealing multifocal tuberculosis.

Case report: A 65 year old female patient with no context of immunosuppression, presented to emergency department with Consciousness disturbance associated with severe hyponatremia, revealing a primary adrenal crisis confirmed with low plasma cortisol and high ACTH levels. Computed tomography (CT) revealed Bilateral adrenal masses with calcifications measuring 20 mm and 16 mm for the left and the right mass respectively. Both have a spontaneous density of 33 UH, and absolute wash of 27% and 11%. CT chest revealed micronodules in the posterior upper lobe of the left lung, multiple calcification zones and mediastinal lymph nodes. The patient presented also a skin temporal lesion, having the clinical presentation of tuberculosis lupus. The biopsy showed a giant epithelioid cell granuloma without caseating, with a positivity of Gene-Xpert. HIV serology and viral hepatitis were negative The diagnosis of multifocal tuberculosis including pulmonary, adrenal and skin localisation was established. The symptoms of primary adrenal insufficiency gradually subsided after the initiation of Hydrocortisone replacement in addition to antituberculous therapy.

Discussion: Although autoimmune adrenalitis is the most common cause of primary adrenocortical insufficiency, Tuberculous Addison’s disease (TAD) is still common particularly in endemic countries. This condition could be inaugurated by an Addisonian crisis, as it is the case for our patient. Tuberculosis may directly involve the adrenal glands which classically appears after more than 90% of the adrenocortical destruction by tuberculosis. Following Hematogenous and lymphatic dissemination, the adrenal localisation is often not apparent for as many as 10 years after tuberculosis infection. Generally, in the early and active stages of tuberculosis, adrenal glands are enlarged, while long-term disease will have small, atrophic adrenals, and calcification due to degeneration process. Multifocal tuberculosis is a severe form of the disease, usually affecting immunocompromised individuals who already have a pulmonary localization. However, it can also affect immunocompetent subjects with or without pulmonary involvement. It is therefore necessary to systematically carry out an exhaustive assessment of the dissemination of the tuberculosis germ, in order to improve the disease management. Prognosis is often favorable, depending on the type of the disease localisation and the early initiation of anti-tuberculosis drugs.