Histoplasmosis associated with Addison's disease

Abstract

A 60-year-old female farmer and resident of the hinterlands of Rio Grande do Sul (southern Brazil) had a history of treatment for depression (sertraline, 50mg daily) and widespread pain. Clinical and laboratory examinations revealed mild gastritis, gastric mucosal atrophy, and osteoporosis. She reported continued use of fludrocortisone and prednisone for the treatment of Addison’s disease, which had been diagnosed previously. A total abdominal ultrasound revealed the presence of two solid nodular lesions: one measuring 5cm in diameter, located in the region of the right adrenal gland, and the other measuring 5.7cm at its greatest diameter and located in the region of the left adrenal gland. Histological analysis of hepatic fragments revealed steatosis affecting approximately 20% of hepatocytes and fibrous portal expansion with rare septa formation. Iron overload was not observed (Figure A). Extensive areas of necrosis and peripheral fibrosis were observed in the suprarenal fragments (Figure B). The pericystic lymph node showed granulomatous lymphadenitis. Grocott’s methenamine silver staining revealed the presence of fungal elements characteristic of Histoplasma capsulatum in the suprarenal fragments (Figure C), lymph nodes, and liver histological sections, which confirmed the diagnosis of histoplasmosis. The patient was treated with 100 mg of itraconazole twice a day for a year, during which time she presented a good clinical condition. This case illustrates the fact that infection of the adrenal glands caused by H. capsulatum, particularly in endemic areas, should be considered and included in the differential diagnosis of diseases of the adrenal glands.