Case Of Primary Adrenal Insufficiency Research Articles

Primary adrenal insufficiency developed 22 years after the diagnosis of light and heavy chain deposition disease: a case report.

Monoclonal immunoglobulin deposition diseases (MIDDs), including light and heavy chain deposition disease (LHCDD), are rare and heterogeneous disorders associated with underlying B-cell clonal disorders. Adrenal involvement is a potential extrarenal manifestation of MIDDs; however, limited data are available regarding its prevalence and clinical presentation. Herein, the present report describes, for the first time, a case of primary adrenal insufficiency that developed twenty-two years after a diagnosis of LHCDD had been made. A 69year-old woman with a 10year history of hemodialysis suddenly became bedridden after falling down stairs in the absence of focal neurological deficits. Subsequently, she experienced appetite loss, nausea, vomiting, a fever of unknown origin, and unexplained hypotension. Several months later, primary adrenal insufficiency and normal pressure hydrocephalus were diagnosed and successfully managed. The long-term clinical prognosis of MIDDs has not been fully elucidated despite recent advances in the management of the disorders. This report may contribute to improving our understanding of the disease course.

A Case of Primary Adrenal Insufficiency Triggered by Cytomegalovirus Infection after Obinutuzumab plus Bendamustine Therapy for Follicular Lymphoma.

A 69-year-old man was diagnosed with follicular lymphoma (Grade 3A). Obinutuzumab combined with bendamustine (OB) therapy was initiated as salvage chemotherapy. Nausea, abdominal pain, and hyponatremia appeared after six courses of OB therapy; cytomegalovirus (CMV) enteritis with primary adrenal insufficiency (PAI) was a complication. Ganciclovir and hydrocortisone were administered, and the clinical findings improved. PAI caused by CMV infection has mainly been reported in patients with acquired immunodeficiency syndrome. In the present case, the PAI triggered by CMV infection led to immunodeficiency after chemotherapy.

Adrenal Hemorrhage in Patients with Systemic Lupus Erythematosus and Antiphospholipid Syndrome: A Case Report and Literature Review.

Antiphospholipid syndrome (APS) is an autoimmune disorder while adrenal hemorrhage could be its rare complication. Herein, we report the case of a 32-year-old unmarried woman with a history of systemic lupus erythematosus (SLE) who was hospitalized after complaints of upper abdominal pain, limb weakness, and loss of appetite for 2 weeks. Laboratory examination revealed hyponatremia, low plasma cortisol levels, increased adrenocorticotropic hormone levels, and a positive anticardiolipin antibody status. Furthermore, computed tomography (CT) revealed the presence of bilateral adrenal masses. Ultimately, based on dynamic changes in CT images, these masses were diagnosed as adrenal hemorrhage owing to APS. A computer-assisted literature search was conducted to identify cases of primary adrenal insufficiency associated with APS and/or SLE. The clinical features, laboratory examination, treatments, and outcomes of these cases were summarized. Our findings emphasize the importance of screening for adrenal insufficiency in patients with SLE or APS who present with abdominal complaints, asthenia, and hyponatremia. It is also recommended to test for APS all patients with adrenal hemorrhage.

Endocrine disorders associated with COVID 19. Adrenal insufficiency

COVID‑19 has a negative impact not only on the respiratory system, but also on other organs and systems, including the endocrine. Cases of lesions of the hypothalamus, pituitary gland, thyroid gland, adrenal glands, gonads and pancreas are described. Hypocorticism in COVID‑19 patients can be caused by various reasons: damage to the adrenal endothelium, bilateral hemorrhages and heart attacks. Adrenal insufficiency in patients with COVID‑19 can have a negative impact on the prognosis of coronavirus infection. A clinical case of primary adrenal insufficiency is presented. The patient was hospitalized three times within 2 months with complaints of dyspeptic phenomena, weight loss. A sharp increase in complaints was noted after the transferred COVID‑19. The diagnosis of adrenal insufficiency was assumed after the appearance of a specific brown color of the skin. Hypocorticism has been confirmed in the laboratory. Cases of primary adrenal insufficiency after COVID‑19 can cause difficulties in diagnosis, because clinical manifestations are similar to the phenomena of post-ovoid syndrome in the form of asthenic syndrome: weakness, decreased appetite, weight loss.

ODP631 Infectious Disease Causing Damage Of The Adrenal Glands, A Life Threating Event

Abstract Introduction Primary Adrenal Insufficiency (PAI) is not a common cause of adrenal insufficiency. The most common cause is Addison disease that is an autoimmune condition. Other causes include hemorrhage, infiltration, infections, necrosis and metastasis. We present a rare case of primary adrenal insufficiency caused by disseminated histoplasmosis. Case presentation 87 yo male from the Midwest with a history of HTN, HLD, CAD s/p CABG was admitted to our hospital for fatigue and 15 lbs weight loss. In the ED, he was found to have persistent hypoglycemia (BG in the 50s mg/dl after several vials of D50%). He was admitted to ICU for continuous D10% infusion. His laboratory showed Na 137mmol/L, K 3.7mmol/L. Further work up for hypoglycemia showed BG of 53 mg/dl with C-peptide of 0.92ng/ml and Insulin <1uIU/ml. Due to the concern of non-insulin dependent hypoglycemia, AM cortisol was done which was low7ug/dl. Immediately, he was started on high dose hydrocortisone. Head CT was negative for pituitary lesions. CT showed lung nodules and bilateral peripherally calcified adrenal lesions 3.6 & 2.6 cm homogenous, well defined borders (HU 20-30). Adrenal hormones work up showed normal metanephrines, Aldosterone <1ng/dl and PRA 1.35ng/ml/h (0.25-5.82). ACTH stim test revealed cortisol level of 9. 0 ug/dl, 9.4 ug/dl, and 9.2 ug/dl at baseline, 30min and 1hr respectively with a baseline ACTH of 539. Lung biopsy showed necrotizing granuloma and fungal spores compatible with histoplasmosis. He was started on amphotericin then transition to itraconazole for 1 year. Additionally, the dose of HC was decrease and Fludrocortisone 0.1mg daily was added. He refused adrenal biopsy at that point and wanted to continue current treatment with a plan to repeat imaging in 3 months and possible adrenal biopsy depending on CT results. On follow-up, patient regained weight and hypoglycemia resolved. Repeated adrenal CT showed shrinkage of the adrenal nodules bilateral. He was continued on PAI replacement. Discussion Histoplasmosis is a fungal infection caused by (H. capsulatum), found in soil contaminated with bird or bat droppings. Infection usually limited to respiratory disease in immunocompetent host but may cause disseminated infection in immunocompromised patient which can involve any organ system. Less commonly, disseminated type may occur in an immunocompetent host with the adrenal gland being the most common infected organ. Treatment involves systemic antifungal therapy; ketoconazole or itraconazole for mild-moderate forms and amphotericin B for 12-18 months for severe ones. Relapse rate is high; ∼ 7.5% and most patients require long-term glucocorticoid replacement. Because unrecognized disseminated histoplasmosis accompanying PAI usually results in a high mortality rate, considerable suspicion and appropriate investigations are necessary for correct diagnosis of this rare but treatable disease. Presentation: No date and time listed

GNAS mutation is an unusual cause of primary adrenal insufficiency: a case report

BackgroundPrimary adrenal insufficiency in children has non-specific and extensive clinical features, so the diagnosis of its etiology is complex and challenging. Although congenital adrenal hyperplasia is the most common cause, more and more other genetic causes have been identified. GNAS mutation is easily overlooked as a rare cause of primary adrenal insufficiency. Here we firstly report a neonatal case of primary adrenal insufficiency caused by GNAS mutation.Case presentationA boy was diagnosed with congenital hypothyroidism 10 days post-partum and treated immediately. He also had persistent hyperkalaemia and hyponatraemia with elevated adrenocorticotropic hormone. At 70 days after birth, he was transferred to our hospital on suspicion of congenital adrenal hyperplasia. Physical examination found no other abnormalities except for growth retardation. Laboratory examination revealed increased aldosterone and normal cortisol, 17-hydroxyprogesterone, and androstenedione levels. Abnormally elevated parathyroid hormone was accompanied by normal blood calcium. Genetic assessment found a de novo, heterozygous c.432 + 1G > A variant in GNAS.ConclusionsWe report this case to highlight that GNAS mutation is an unusual cause of primary adrenal insufficiency. The combination of primary hypothyroidism and /or pseudohypoparathyroidism will provide diagnostic clues to this condition.

Aggregation of autoimmunity in extended families of people with autoimmune Addison disease.

Autoimmunity accounts for 90% of cases of primary adrenal insufficiency (Addison disease (AD)). Affected people present a significant co-occurrence of autoimmune conditions; hence, clustering of autoimmunity is also predicted among their relatives. To evaluate the burden of autoimmunity in families of people with AD. A total of 116 individuals with AD was surveyed regarding the occurrence of 23 autoimmune diseases among their relatives. A total of 74.1% of persons with AD reported at least one relative with an autoimmune disorder - 257 cases were diagnosed in 221 relatives. Hashimoto thyroiditis was found in 100 individuals, followed by Graves disease and vitiligo, in 25 and 24 relatives respectively. Type 1 diabetes was diagnosed in 23 relatives, psoriasis in 15, rheumatoid arthritis in 12, pernicious anaemia in 11, multiple sclerosis in 8, and premature menopause in 8 women. AD was found in seven relatives, alopecia in six and celiac disease in five. Other conditions were rare. Significant correlation was noticed between the number of autoimmune conditions in AD proband and the number of affected relatives (P = 0.031). A total of 66.4% of people with AD had a first-degree relative suffering from autoimmunity. Autoimmune conditions were more frequent among females: sisters (P < 0.001), mothers (P = 0.002) and grandmothers (P = 0.002). Considerable prevalence of autoimmune conditions in relatives of people with AD confirms substantial risk of autoimmunity, especially in females and relatives of patients affected by multiplex autoimmunity. Our data corroborate the recommendation of active screening for autoimmune disorders, particularly thyroid disease, among AD family members.

Endocrinopathies Associated with Immune Checkpoint Inhibitors

Immune checkpoint inhibitors (ICIs) are monoclonal antibodies that increase the efficiency of the immune system in the destruction of neoplastic cells. In recent years, these drugs have been increasingly used in the treatment of many neoplasms in advanced stages. However, the change in the regulation of the immune system induced by these drugs has the potential adverse effect of inducing autoimmunity in practically all organ systems. Endocrinopathies are one of the most common autoimmune adverse eventsof these drugs. Non-systematic review of endocrinopathies reported in the context of treatment with ICIs. A search was carried out on PubMed until January 31st, 2020, and articles were selected based on their relevance and excluded in case of redundant content. The following search terms were used: "immune checkpoint inhibitor" and "endocrinopathy" / "endocrine system diseases" / "pituitary" / "thyroid" / "diabetes" / "adrenal" / "parathyroid". Endocrinopathies with all classes of ICIs (anti-CTLA-4, anti-PD-1, anti-PD-L1) have been reported. Thyroid dysfunction is the most frequently reported endocrinopathy, mainly with anti-PD-1 and anti-PD-L1. Hypophysitis is the most prevalent with anti-CTLA-4. The incidence of autoimmune diabetes in this context is increasing, mainly with anti-PD-1 and anti-PD-L1. Rare cases of primary adrenal insufficiency, Graves' disease and primary hypoparathyroidism have also been reported. Knowing the spectrum of endocrinopathies triggered by ICI, as well as their clinical features, diagnosis and treatment criteria is essential, given its high prevalence and the increasing number of cancer patients treated with these new drugs.

Abstract #1001397: Adrenal Insufficiency Related to Primary Adrenal Lymphoma

Primary adrenal insufficiency (AI) is characterized by insufficient cortisol and aldosterone levels due to gland destruction. Fatigue and weight loss are common symptoms of adrenal insufficiency that may be overlooked in patients with malignancy, leading to a delay in diagnosis. We present a case of primary adrenal insufficiency caused by bilateral adrenal diffuse large B cell lymphoma in a 76-year-old male.

PD-1 Inhibitors Induced Primary Hypoadrenalism

Abstract Background: Primary adrenal insufficiency is known to be induced by certain medications, including anesthetics, antimycotic and antiparasitic medications. However, it is rarely being reported that caused by antitumor immune checkpoint inhibitors PD-1. Clinical Case: A 82-year-old female with a significant history of lung adenocarcinoma status post of recent Pembrolizumab therapy. She presented with multiple complaints, including increasing confusion, mainly memory loss, generalized aches, and pains who was found to have recurrent hyponatremia with a sodium level of 122, treated with water restriction and sodium tablets. Initial screening labs were suggestive of adrenal insufficiency: level of ACTH was within the normal range (11 pg/dL, normal range 7.2–63 pg/dL), level of cortisol was low (1.6 ng/dL, normal range 3–23 pg/dL). MRI brain without contrast ruled out metastatic disease. An ACTH-stimulating test was performed, with the results revealing an inadequate cortisol response at 0, 30, and 60 minutes(1.4 ug/gl, 8.5 ug/dl, 11.9 ug/dl, normal range 18–20 ug/gl). Therefore, a diagnosis of primary adrenal insufficiency was made. The patient was prescribed a daily oral dose of 5 mg of hydrocortisone. Her symptoms improved after a few days, and her hydrocortisone gradually increased to 15 mg daily, and her energy and memory were back to baseline after six months. Conclusion: This is a rare case of primary adrenal insufficiency caused by Pembrolizumab using for non-small lung cancer treatment. With the growing use of Pembrolizumab, it is necessary to be aware of possible adrenal insufficiency that could be associated with receiving pembrolizumab therapy amid any clinical suspicion. Reference: Chang, L.S., et al., Endocrine Toxicity of Cancer Immunotherapy Targeting Immune Checkpoints. Endocr, Rev, 2019. 40(1): p. 17–65

Spectrum of adrenal disorders in a referral hospital of Bangladesh

Background: Adrenal diseases are common and their presentations are variable. This study aimed to determine the frequency and presenting features of various adrenal diseases in a tertiary care hospital of Bangladesh.&#x0D; Methods: This retrospective descriptive study was carried out in Endocrinology in-patient department of BIRDEM General Hospital, Dhaka, Bangladesh, from October 2017 to December 2018. During this time, total 745 patients were screened; out of whom 91 had adrenal diseases.&#x0D; Results: Mean age of the study population was 39.6±11.5 years. Among them, 65.9% were male. Most (75.8%) cases had adrenal insufficiency, followed by endogenous Cushing’s syndrome (8.8%), Conn’s syndrome (6.6%), non-functioning adenoma (3.3%), congenital adrenal hyperplasia (CAH) (2.2%), pheochromocytoma (1%), myelolipoma (1%) and adrenal carcinoma (1%). According to functional status, most (75.8%) were hypofunctional. Of the patients with adrenal insufficiency, secondary adrenal insufficiency was the most common (78.3%). Among the secondary adrenal insufficiencies, 75.9% had iatrogenic adrenal insufficiency and 24.1% had pituitary diseases. Regarding the cases of primary adrenal insufficiency, 20% cases were due to adrenal tuberculosis, 6.6% were due to adrenal histoplasmosis and 73.3% were idiopathic. Most of the adrenal insufficiency patients presented with hypotension (66.7%), followed by gastrointestinal symptoms (76.8%), weight loss (55.1%), hyponatraemia (42%), pigmentation (13%) and hypoglycemia (10%). In this study, 9.9% patients had adrenal incidentaloma. Most of them (88.9%) were benign. Causes of Cushing’s syndrome among the study population were, iatrogenic (66.7%), adrenal (16.7%) and pituitary cause (16.7%). In this study, 16.5% patients had endocrine hypertension and the causes were endogenous Cushing’s syndrome (53.3%), Conn’s syndrome (40%) and pheochromocytoma (6.7%). Of the hypertensive patients, 60% had co-existing hypokalemia.&#x0D; Conclusion: Adrenal insufficiency was the most common adrenal disorder followed by endogenous Cushing’s syndrome, Conn’s syndrome, non-functioning adenoma and other adrenal disorders. Presentations of adrenal disorders are variable. Among the cause of adrenal insufficiency iatrogenic adrenal insufficiency was the most common.&#x0D; Birdem Med J 2021; 11(2): 103-107

Adrenal failure and antiphospholipid syndrome.

We herein report two cases of primary adrenal insufficiency (AI) associated with antiphospholipid syndrome (APS). In both patients, the main finding that led to the diagnosis was hyponatraemia. The major difference between the two cases was the time at which AI evolved during the course of APS. In the first patient, AI developed acutely along with other presenting features of APS. In the second patient, the AI was unmasked during a stressful situation induced by severe inflammation that occurred 7 years after the first APS manifestation and had probably evolved slowly during the previous few years. These cases emphasise the importance of considering AI in patients with either suspected or newly diagnosed APS as well as in patients who have long been known to have APS. The symptoms and signs alerting the clinician to possible AI are general abdominal complaints, fever, hypotension, and hyponatraemia. Conversely, patients with primary AI should be questioned about the signs and symptoms of APS.

Addisonian hyperpigmentation in a case of late onset familial glucocorticoid deficiency and dramatic improvement with glucocorticoid supplementation

Addison's disease is a chronic endocrine disorder in which the adrenal glands do not produce enough steroid hormones mostly both glucocorticoid and mineralocorticoid. Most common causes of primary adrenal insufficiency are due to autoimmune adrenalitis in developed world, and tuberculosis in developing world. Here we present a rare case of primary adrenal insufficiency with addisonian pigmentation secondary to familial glucocorticoid deficiency.

A case of late manifestation of primary adrenal insufficiency in the autoimmune polyglandular syndrome type 1

The article describes a clinical case of primary adrenal insufficiency which manifested at an atypically advanced age. Primary adrenal insufficiency combined with other clinical symptoms suggested the autoimmune polyendocrine syndrome type 1. Subsequently, the diagnosis was confirmed by the results of genetic testing. The particulars of the clinical case include the age of patient at manifestation of the disease (49 years). The lack of treatment resulted in dramatic clinical decompensation. This clinical case is intended to draw clinicians' attention to the necessity of detection of primary adrenal insufficiency and appropriate and timely treatment. Taking into account eventual diagnostic problems, it is necessary to raise awareness about this disease among practicing doctors of various specialties.

MON-359 Primary Adrenal Insufficiency Secondary to Chronic Use of Posoconazole: A Case Report

Cortisol attenuates inflammatory responses, contributes with glucose homeostasis, and enhances vascular smooth muscle tone augmenting blood pressure among other functions. The symptoms and signs of adrenal insufficiency (AI) depend upon acuity and degree of loss of the adrenal function, including whether mineralocorticoid production is preserved or not. A 65 years-old male with past medical history of mixed connective tissue disease developed 2 weeks of fever and was diagnosed with hemophagocytic lymphohistiocytosis for which he was placed on HLH-94 protocol (ectoposite and high dose pulse steroids). He was also found to have invasive murcomycosis initially treated with amphotericin and posacolonazole(PSO). Given the culture results, amphotericin was stopped and PSO 500mg daily was continued. The patient had a complicated hospital course and was discharged on 2mg of dexamethasone with a pertinent taper. He developed weakness and failure to thrive. His dexamethasone was increased to 3mg daily by his oncologist, and his PSO and chemotherapy was continued. Due to worsen fatigue and deconditioning the patient was brought to the Emergency Room. Upon arrival he was noticed to have persistent orthostatic hypotension despite intravenous fluids, hyponatremia and hyperkalemia (what is the potassium) suggestive of mineralocorticoid deficiency. Further endocrinology workup revealed plasma renin activity of 16.7ng/ml/hr (0.167-5.380) with a low aldosterone level of 1.6ng/dl (0.0-30). CT abdomen imaging showed intact adrenal glands bilaterally. Patient was diagnosed with PSO induced primary AI, he was placed on fludrocortisone with significant symptoms improvement and normalization of electrolytes and blood pressure. After a thorough literature review we found two case reports of iatrogenic Cushing in patients using Fluticasone and PSO, three cases of steroid induced secondary AI in patients treated with inhaled budesonide and PSO; and two cases of primary adrenal insufficiency in patients using PSO without steroids. PSO effects in the adrenal axis are rare, clinicians should be aware of their potential effects on the hypothalamic-pituitary-adrenal axis and pharmacologic interactions with steroids.

MON-LB064 A Zebra of Adrenal Insufficiency: What Was Once Common Is Now Rare

Background: TB was once a common cause of primary adrenal insufficiency, it is now most often autoimmune in the developed world, but there are rarely observed infectious causes, including TB, Fungal, and CMV. The extra-adrenal manifestations typically stem from pulmonary TB. When TB invades the adrenals, imaging of the adrenal glands initially shows hypertrophy, which progresses to fibrosis and calcification in almost half the cases. This adrenal hypertrophy is often a key marker for differentiating tuberculous adrenal insufficiency from autoimmune adrenalitis, in which case adrenals are usually atrophied. Case: A 62 year old woman with a history of CKD, hyperlipidemia, and possible heart failure presented to the hospital with a 3 week history of worsening right knee pain. She was initially hypotensive at 68/48. Her hospital course was complicated by renal failure, persistent hypotension, and hyponatremia. She received approximately 5 liters of fluid with no significant hemodynamic response. Initial labs showed sodium of 125 with normal range 135-145 and a creatinine of 3.63 with sodium levels hovering in the low 130’s throughout the next 8 days while systolic pressure remained less than 110. Endocrinology was consulted to evaluate the ongoing hypotension and hyponatremia 5 days into admission. Infectious disease was also consulted after it was later revealed that the patient had a history of TB with a positive ppd in 2014, treated with Isoniazid but she was unable to confidently state whether she completed treatment. Other lab work was remarkable for a positive ppd test, negative HIV, and random cortisol levels of 1.3 and 1.1. Cosyntropin stimulation test was very abnormal with cortisol results of 1.3 and 1.1 at 30 and 60 minute intervals (normal >18). ACTH on day 6 of admission was greater than 2000, consistent with primary adrenal insufficiency. Abdominal CT without contrast on day 11 showed adrenal fullness with nodal calcifications consistent with post-infectious TB. Blood pressure and sodium improved on hydrocortisone 50 mg three times daily. She was discharged on hydrocortisone 20mg in the AM and 10mg in the PM, fludrocortisone 0.1mg daily and the 4 drug combo for TB; Rifampin, Isoniazid, Pyrazinamide, and Ethambutol. Conclusion: This case of primary adrenal insufficiency highlights an atypical cause that is now rare in the developed world. TB causes adrenal destruction in a gradual manner, targeting the medulla and cortex secondarily as illustrated here by this HIV-negative latent TB patient. Tuberculous adrenal insufficiency typically presents in an insidious manner. This case demonstrates the importance of a thorough history and evaluation coupled with the realization that not all primary adrenal insufficiency is autoimmune. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. s presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

Primary Adrenal Insufficiency due to a Hypercoagulable State

To illustrate a case of primary adrenal insufficiency caused secondarily to eosinophilic granulomatosis with polyangiitis, case report and review of the literature are used. An example of primary adrenal hemorrhage due to a hypercoagulable state with a thorough discussion and review of the literature. Although rare a hypercoagulable state can lead to bilateral adrenal hemorrhages and subsequent primary adrenal insufficiency. Keeping this in mind can lead to prompter diagnosis and treatment. J Med Cases. 2018;9(7):233-235 doi: https://doi.org/10.14740/jmc3100w

Primary Adrenal Insufficiency from Immune Checkpoint Inhibitors

Objective: To describe a rare case of primary adrenal insufficiency (PAI) from immune checkpoint inhibitors (ICPIs). Methods: We describe the clinical presentation, supportive laboratory findings, long-term outcomes, and a review of the current available literature on PAI following administration of ipilimumab and nivolumab. Results: A 49-year-old Caucasian male with stage IIIB metastatic melanoma and failed standard chemotherapy and monotherapy with ipilimumab was started on nivolumab in addition to ipilimumab. Two months after starting the combination therapy, he presented with weakness, lethargy, nausea, and diarrhea for 1 to 2 weeks. Since there was a concern for treatment-associated endocrinopathy, an 8 am cortisol and adrenocorticotrophic hormone (ACTH) were measured and noted to be 5.4 μg/dL (normal, 5 to 25 μg/dL) and 224 pg/mL (normal, 15 to 66 pg/mL), respectively. The cortisol was interpreted as normal, and follow-up was arranged in the endocrinology clinic. ACTH was drawn at the same time but ...

Primary Adrenal Insufficiency due to a Hypercoagulable State

To illustrate a case of primary adrenal insufficiency caused secondarily to eosinophilic granulomatosis with polyangiitis, case report and review of the literature are used. An example of primary adrenal hemorrhage due to a hypercoagulable state with a thorough discussion and review of the literature. Although rare a hypercoagulable state can lead to bilateral adrenal hemorrhages and subsequent primary adrenal insufficiency. Keeping this in mind can lead to prompter diagnosis and treatment. J Med Cases. 2018;9(7):233-235 doi: https://doi.org/10.14740/jmc3100w

Primary Adrenal Insufficiency due to Multidrug-Resistant Tuberculosis: A Case Report

Tuberculosis (TB) is a common infectious disease in developing countries like Bangladesh. Drug-resistant tuberculosis (DR-TB) poses a significant threat to the population. A relatively uncommon site of involvement of TB is adrenal gland, which is an important cause of chronic adrenal insufficiency. Here we present a case of a 40-year-old male with multidrug-resistant tuberculosis (MDR-TB) involving the adrenal glands. He was previously diagnosed as a case of disseminated TB involving lungs, right knee joint and lumbar spine and received anti-TB chemotherapy for several occasions and in different categories in last 12 years before this presentation. He presented with 4-month history of vomiting, diarrhea, generalized weakness, generalized pigmentation and postural hypotension. Investigations revealed hyponatremia with hyperkalemia. Adrenal insufficiency was suspected and serum cortisol was found to be low and serum adreno corticotropic hormone (ACTH) was high. On imaging there was bilateral adrenal enlargement. Fine needle aspiration cytology (FNAC) was done from adrenal gland which revealed granulomatous lesion suggestive of TB. Gene Xpert and culture-sensitivity of aspirated material for Mycobacterium tuberculosis revealed MDR-TB. Patient was finally diagnosed as a case of primary adrenal insufficiency due to MDR-TB of the adrenal glands and was treated with regime for MDR-TB for 20 months.Birdem Med J 2017; 7(3): 235-237