Acute Adrenal Insufficiency as the Primary Manifestation of Extrapulmonary Tuberculosis: A Case Report

Abstract

Acute adrenal insufficiency (AI) is a life-threatening condition. While Addison's disease (AD) is rare, in developing countries, tuberculosis (TB) still remains as the primary cause in 7 to 20% of cases. Urinary TB is also the third most common form of extrapulmonary disease. We report a case of 37-year-old male who presented with weakness, anorexia, weight loss, dysuria, flank pain and low grade fever. Examination revealed hypotension, hyperpigmentation, hyponatremia, hypoglycemia and low serum cortisol. He was diagnosed to have adrenal crisis due to Addison's disease and extrapulmonary TB manifesting as urinary tract infection (UTI). He was treated with corticosteroids and anti-TB medications. Urologic reconstructive surgery was subsequently planned..

A Camouflaged Case of Disseminated Tuberculosis Presenting as Adrenal Crisis

“…Very few patients are known to recover complete adrenal function following completion of anti-tubercular therapy in Addison's disease secondary to tuberculosis particularly if the gland develops calcification and becomes atrophic [8], [9]. Recovery relies on the amount of adrenal tissue destruction caused by tuberculosis and the presence of viable tissue at the time of diagnosis [10].…”

“…Anti-tubercular drugs are also not required if adrenal glands are atrophic and calcified as recovery is unlikely [8], [10]. Rifampicin has been previously reported to shorten the half-life of steroids along with impairment of the therapeutic response as it is a strong inducer of the cytochrome P450(CYP) system which is involved in the metabolism of adrenocorticoids.…”

Adrenal Tuberculosis Leading to Acute Adrenal Insufficiency

“…Addison's disease is a rare disorder with an estimated prevalence of approximately 120 individuals in one million. (7,8,9) Adrenal glands can be primarily affected by infections such as tuberculosis and Histoplasmosis, despite located in the retroperitoneum. When adrenal insufficiency was first identified by Dr. Thomas Addison in 1849, tuberculosis was found at autopsy in 70 to 90 percent of cases.…”

“…As the incidence of tuberculosis declined and treatment improved, the incidence of adrenal tuberculosis has declined. (8,10) Primary adrenal insufficiency or Addison's disease affects about 1 in 100,000 people. Adrenal insufficiency occurs when at least 90 percent of the adrenal cortex has been destroyed.…”

“…About 70-80% of reported cases of Addison's disease are caused by autoimmune disorders, 20% by tuberculosis and rest are idiopathic. (8,9,11) In most cases, symptoms are severe enough so that patients seek medical treatment before a crisis occurs. However, in about 25 percent of patients, symptoms first appear during an Addisonian crisis which includes (a) sudden penetrating pain in the lower back, abdomen, or legs (b) severe vomiting and diarrhea (c) dehydration (d) low blood pressure (e) loss of consciousness.…”