Rifampicin-induced adrenal crisis in a patient with tuberculosis: a therapeutic challenge

Abstract

A 55-year-old Indian man presented with productive cough and a large left pleural effusion. Pleural fluid culture grew Mycobacterium tuberculosis, and he was started on antituberculosis therapy. One week later, the patient presented to hospital with drowsiness, dehydration and hypotension. He was transferred to critical care and only improved after starting hydrocortisone and stopping rifampicin. His short synACTHen test subsequently confirmed primary adrenal insufficiency, and a CT of the abdomen showed bilateral adrenal enlargement. Rifampicin is known to accelerate cortisol metabolism. We report the rare case of a rifampicin-induced adrenal crisis as a first presentation of Addison's disease in a patient with tuberculous infiltration of the adrenal glands.

Systemic Manifestation of Miliary Tuberculosis in Patient With Advanced Diabetic Retinopathy Presenting With Electrolyte Imbalance, Seizures, and Adrenal Insufficiency

“…Lack of restoration of adrenocortical function after TB chemotherapy can also be suggestive of adrenal TB, although adrenal insufficiency may be overt by this stage [9]. In fact, as a hepatic cytochrome P450 enzyme inducer, rifampicin accelerates corticosteroid metabolism, and has previously precipitated acute adrenal crisis [10]. Therefore high-dose hydrocortisone is advisable in patients with adrenal insufficiency with suspected direct TB involvement [7,8].…”

Unilateral adrenal tuberculosis whose computed tomography imaging characteristics mimic a malignant tumor: A case report

“…Patients with adrenal TB are usually treated with standard quadruple antitubercular treatment (such as isoniazid, rifampicin, pyrazinamide, and ethambutol)[ 18 - 20 ] for nearly 12 mo or longer. Adverse reactions to anti-TB drugs and their interactions with corticosteroids that are administered for replacement therapy remain challenging[ 21 , 22 ].…”

“…Up to 70% of patients with active TB have subclinical adrenal insufficiency[ 24 ]. Anti-TB treatment might cause adrenal crisis[ 18 ], and patients should be closely monitored when starting this treatment. Most of the cases demonstrated a good response to anti-TB treatment.…”

Tuberculosis adrenal en un paciente inmunocompetente: reporte de un caso

“…Se han propuesto varios mecanismos por los que la infección por M. tuberculosis genera insuficiencia suprarrenal, los cuales incluyen: • La rifampicina puede inducir insuficiencia suprarrenal al acelerar el metabolismo del cortisol (9) . Es un inductor de citocromo P-450 que puede aumentar el metabolismo de hormonas como el cortisol; esto debido a la actividad 6B-hidroxilasa del citocromo (10,11) . Sin embargo, dada su alta efectividad para el tratamiento de la tuberculosis, se consideró continuarla a pesar de la insuficiencia suprarrenal del paciente.…”

“…Al comparar nuestro caso con otros casos reportados se encontró similitud en el diagnóstico previo de infección pulmonar o pleural (8,10) ; sin embargo, hay otros casos con diagnóstico de insuficiencia suprarrenal durante infección diseminada (22,23) , de forma aislada (24,25,26) o antes del diagnóstico de tuberculosis pleural o pulmonar (27) lo que demuestra la variedad del espectro clínico de la infección por Mycobacterium tuberculosis.…”