Endocrinology Fellow Cooper University Health Care Philadelphia, Pennsylvania, United States
Introduction : Historically, bilateral adrenal gland destruction by tuberculosis (TB) was the most common cause of primary adrenal insufficiency. However, its incidence has significantly decreased in the developed world, where autoimmune adrenal insufficiency now constitutes most reported cases, ranging from 70-90%. Adrenal tuberculosis typically arises after pulmonary or genitourinary TB, although rare instances manifest as isolated TB.
Case(s) Description : A 73-year-old man with a history of tuberculosis presented to endocrinology for evaluation of adrenal insufficiency. He reported being initially diagnosed in his 20s when he presented with weight loss, hyperpigmentation, and fatigue. He reported being exposed to TB as a fetus but did not develop symptoms until much later in life. During the initial presentation, he was treated for TB, which did not improve his symptoms. He subsequently started on Prednisone, which he tapered over the next couple of years, until stopping in 1994. By the time he is evaluated by us, he has been off steroids since then. On our evaluation, he reported weight loss, hyperpigmentation, and fatigue. Further evaluation showed an ACTH of >2000 pg/mL [7.2 - 63.3 pg/mL] and 8 am cortisol of 2.6 ug/dL [6.2 - 19.4 ug/dL], confirming adrenal insufficiency. Antibodies for 21-hydroxylase were evaluated and resulted negative, ruling out autoimmune adrenal insufficiency. He underwent a CT scan of adrenal glands with and without IV contrast, which showed a completely calcified and enlarged right adrenal gland, and nearly completely calcified left adrenal gland. He was started on glucocorticoid and mineralocorticoid replacement therapy which resulted in weight gain and improved energy.
Discussion : In the developed world, autoimmune adrenalitis stands as the prevailing etiology for primary adrenal insufficiency. This case underscores the critical need for a comprehensive diagnostic approach, especially when autoimmune causes are eliminated, prompting consideration of alternate etiologies, such as TB-related adrenal destruction.
