A 41‐year‐old Indian man vacationing in the United States presented with a 2‐day history of vomiting and lightheadedness. He had been vomiting at least 6 times a day and felt extremely thirsty. Review of systems was significant for anorexia and fatigue for a month and no recent cough. Physical examination revealed he was hypotensive and tachycardic, with a blood pressure of 86/63 mm Hg and a heart rate of 120 beats per minute. He had dry mucus membranes and cool extremities. He was placed in pulmonary isolation and started on intravenous steroids and fluids. Initial laboratory tests showed a hematocrit of 53, sodium of 122 mmol/L, potassium of 6 mmol/L, and creatinine of 1.8 g/dL. Acosyntropin stimulation test showed an initial serum cortisol of 1.9 μg/dL, with levels of 2 and 1.9 μg/dL after 30 and 60 minutes, respectively. He had a positive tuberculin skin test of 8 mm. A CT scan of his chest and abdomen showed bilateral adrenal masses with the right adrenal mass containing specks of calcification and an 8‐mm noncalcified left upper lobe nodule with no hilar lymphadenopathy. HIV, CMV, and fungal serologies were negative. Empiric treatment for tuberculosis was commenced, and bronchoalveolar lavage was performed to obtain samples for acid‐fast bacilli and culture. His symptoms resolved within 48 hours, and he was discharged on oral steroids and antituberculous therapy, with follow‐up at the tuberculosis clinic. A culture grew Mycobacterium tuberculosis 4 weeks later. Unfortunately, despite multiple visits to the address provided, this patient was lost to follow‐up.
Adrenal tuberculosis is an infrequent cause of adrenocortical insufficiency in the United States. Adrenal involvement is most often the result of hematogenous spread of pulmonary tuberculosis. Though extraadrenal tuberculosis is usually evident, it may be clinically latent; for this reason, pulmonary tuberculosis precautions should be instituted until active pulmonary disease is excluded. Most cases occur 10‐15 years after the initial infection. Bilateral adrenal calcification is the most common radiologic finding, but the absence of enlarged or calcified adrenal glands does not rule out tuberculosis as the cause of adrenal failure. Adrenal glands may also enlarge in pulmonary tuberculosis that does not involve the adrenal gland but may reduce in size with antituberculous therapy. In adrenal tuberculosis recovery of function is possible after appropriate antituberculous therapy but usually does not occur.
The world has become much smaller as international travel has become more affordable and commonplace. Hence, physicians must think globally as diseases and presentations usually rare in the United States make international borders blur.
A. Agbebi, None; D. Ling, None.
To cite this abstract:Agbebi A, Ling D. Thinking Globally: Adrenal Tuberculosis in an Indian Man on Vacation in the United States. Abstract published at Hospital Medicine 2007, May 23-25, Dallas, Texas Abstract 107. Journal of Hospital Medicine. 2007; 2 (suppl 2). https://www.shmabstracts.com/abstract/thinking-globally-adrenal-tuberculosis-in-an-indian-man-on-vacation-in-the-united-states/. Accessed April 10, 2020.