An old story again with a new patient in modern world: acute adrenal insufficiency in a 51-year old man with vertebral tuberculosis
Inan Anaforoglu1, Ekrem Algun1, Omer Incecayir1 & Cigdem Siviloglu2
Introduction: Tuberculosis is stil an important cause of adrenocortical insufficiency in the devoloping countries. Adrenal insufficiency is usually the result of hematogenous spread of the pulmonary tuberculosis. Adrenal tuberculosis, especially with enlargement of adrenal glands can cause diagnostic problems and requires differentiation from neoplastic disease and fungal infections. Tuberculosis osteomyelitis is a rare form and surgery may be needed. We report a patient with adrenal insufficiency and tuberculosis osteomyelitis.
Case report: A 51-year-old man was admitted to hospital because of anorexia, dizziness, nause, vomiting and weight loss. On admission, his blood pressure was 90/50 mmHg, had severe orthostatic hypotension; the laboratory examination revealed high eritrocyte sedimentation rate (50 mm/h), hyponatremia (121 mEq/l), hyperkalemia (7.5 mEq/l) and low cortisol levels (5 μg/dl). Fluid replacement, methlyprednisolone and fludrocortisone -to correct resistant hyperkalemia- were administered with a diagnosis of adrenal insufficiency. ACTH level was 5.41 pg/ml under corticosteroid and mineralocorticoid treatment. Upper abdomen magnetic resonance imaging (MR) revealed asymmetrical enlargement of adrenal glands compatible with bilateral adrenal hyperplasia. In name of excluding tuberculosis, X-ray of the chest was completely normal. We looked up any pathological lymphadenopathy; the pathological examination of a hypoechoic, 2 cm, non-reactive, inguinal lymph node was compatible with granulomatous lympadenitis which showed caseating granulomas. The patient had been suffering lomber pain for several months. Lomber MR revealed height loss and pathologic signalisation in L1L2 which could be compatible with compression fracture or metastasis. A biopsy of lomber vertebra was performed. The pathological result showed chronic necrotic caseating granulomatous inflammation revealing tuberculosis osteomyelitis. Antituberculotic medicines isoniazid, rifampicin, pyrazinamide were prescribed with steroids.
Conclusion: Adrenal insufficiency due to tuberculosis has become a rare condition for developed countries, however, in a patient from a devoloping country tuberculosis should always come to mind in the differential diagnosis when primary adrenal insufficieny is detected.