FRI236 Primary Adrenal Insufficiency Due To Coccidiomycosis

Abstract

Abstract Disclosure: T. Duro: None. Introduction: Primary adrenal insufficiency due to infectious adrenalitis is not common in the United States. When it occurs, the most common culprits are tuberculosis, histoplasmosis, and HIV-related manifestations. We present a rare case of disseminated coccidiomycosis presenting with hypercalcemia, adrenal insufficiency, and a right adrenal mass. Case Report: A 73-year-old Hispanic man living in New Mexico with history of paraesophageal hernia and a thoracic aortic aneurysm was admitted in the hospital during a COVID-19 infection due to severe weakness, poor oral intake, and abdominal pain. His labs on admission showed: mild eosinophilia, serum calcium corrected for albumin 13.8 mg/dL (n 8.4 - 10.4 mg/dL), PTH <6 pg/mL(n 18 - 84 pg/mL), PTH-rp 4.4 pmol/L (n 0.0 - 2.3 pmol/L), Vitamin D25-OH 18 ng/mL (n >29 ng/mL), Calcitriol 8.1 ng/mL (n 19.9 - 73.9 ng/mL), serum kappa/lambda light chain ratio 2.09 (n 0.29 - 1.65), SPEP and UPEP no M-spike, normal pattern, 8AM serum cortisol 0.9 ug/dL (n5.27 - 22.45 ug/dL), ACTH >1250 pg/mL (n 0 - 46 pg/mL), DHEA-S 20ug/dL (n 80 - 560 ug/dL), plasma normetanephrine 3.29 nmol/L (n 0.00 -0.89 nmol/L), plasma metanephrine <0.10 nmol/L (n 0.00 - 0.49 nmol/L). Abdominal CT scan showed a right hypodense adrenal mass measuring4.8 x 2.4 x 3.7 cm, with small areas of calcification. His left adrenal gland showed thickening and nodularity. Primary adrenal insufficiency was diagnosed based on labs above. He was given high dose IV hydrocortisone which was tapered to PO Hydrocortisone 15mg QAM and 5mg QPM. Fludrocortisone 0.1mg PO daily was also added. His presenting symptoms resolved. Work up for HIV, tuberculosis, and syphilis was negative. His hypercalcemia was thought to be due to acute adrenal insufficiency and less likely related to malignancy or other causes. His mildly elevated PTH-rp was thought to be due to his renal dysfunction, and his mildly elevated kappa/lambda ratio was thought to be non-specific by the oncology consultants after the patient had a negative nuclear bone scan. He was treated with IV fluids and his hypercalcemia resolved. Due to elevated plasma normetanephrines a pheochromocytoma could not be excluded. CT adrenal protocol imaging showed a 4.2 cm right adrenal mass with unenhanced attenuation: 40.6 HU. Absolute washout: 4.0 %, suggestive of hemorrhage. The left adrenal gland was unremarkable on this scan.Alpha and beta blockade were instituted, and the patient underwent aright adrenalectomy. Pathology showed: Necrotizing granulomatous inflammation and coccidioides-like organisms on GMS stain. His coccidioides serum antibodies were positive. He was referred to infectious diseases and was started on fluconazole 400mg daily. He is doing well. Clinical Lessons: Disseminated coccidiomycosis is a rare cause of infectious adrenalitis, but it should remain on the differential diagnosis of primary adrenal insufficiency, especially in endemic areas. Presentation: Friday, June 16, 2023