Bilateral Adrenal Masses Due to Histoplasmosis

Abstract

A 40-YR-OLD diabetic, normotensive man presented with weight loss and epigastric discomfort for 6 months. Chest x-ray was normal. Computed tomography (CT) scan revealed bilateral adrenal masses (Fig. 1A). The second patient, a 58-yr-old hypertensive, nondiabetic man, presented with anorexia and weight loss for 5 months. Chest x-ray revealed mediastinal widening. CT scan showed aortic dissection without mediastinal lymphadenopathy and incidental bilateral adrenal masses (Fig. 1B). Both patients had no history of tuberculosis; their HIV serology was negative. The 250g cosyntropin stimulation test was abnormal in the first patient (peak serum cortisol, 116 nmol/liter); he was commenced on hydrocortisone replacement. Urinary free catecholamine and metanephrine levels were normal in both. CT-guided fine needle aspiration cytology from the adrenal gland (Fig. 2) revealed features of histoplasma species in both; culture confirmed histoplasma capsulatum. They were treated with oral itraconazole (200 mg daily), the first patient for 15 months and the second for 6 months. Follow-up CT scans showed resolution of the adrenal masses in the first patient 5 yr later; he continues to have normal adrenal function at 9 yr. The adrenal masses have reduced in size in the second patient, but remain enlarged in the absence of any clinical disease at 18 months. CT features of adrenal histoplasmosis vary depending on the stage of the disease. Typically, it includes bilateral adrenal masses with peripheral enhancement and central hypodensities, with calcification seen in the healing phase. Similar features might be seen in adrenal neoplasms, subacute adrenal hemorrhage, and other disseminated infections, such as tuberculosis, cryptococcosis, coccidioidomycosis, and blastomycosis (1–5).