Bilateral Small Adrenal Glands in a Patient with Pulmonary Tuberculosis

Presentation Number: SAT-0747
Date of Presentation: June 21st, 2014

Perie Adorable-Wagan*
The Medical City, Pasig City, Philippines

Abstract

Bilateral small adrenal glands in a patient with pulmonary tuberculosis

Perie Adorable-Wagan, MD, FPCP1, Mary Queen Villegas-Florencio, MD, FPSEM2 , Hilario Tamondong, MD,FPCCP3

Fellow in training1, Consultant Endocrinologist2, Section of Endocrinology and Metabolism,  Pulmonologist, Section of Adult Pulmonology3,  The Medical City Hospital, Ortigas Avenue, Pasig City, Philippines

Background

Usual  CT scan findings  of patients with acute PTB have enlarge adrenals with or without calcification, while chronic PTB have smaller adrenal glands, mostly unilateral and rarely bilateral. We report a  not so common finding of  PTB patient with primary adrenal insufficiency having bilateral small adrenal glands on CT scan.

 

Clinical case

A 47 year old male with Type 2 DM,  with a 5 year history of  Pulmonary tuberculosis,   presented with generalized body weakness,  vomiting and  progressive weight loss over 1 month.  Laboratory tests showed hyponatremia at Na 118 mmol/L and K 3.60 mmol/L. Thyroid function test were normal. His serum baseline cortisol level  was low at 0.7ug/dL, and elevated ACTH of 86 pg/ml. (0-46 pg/ml). ACTH stimulation using 250 mcg IV test showed inadequate cortisol response of  2.10 ug/dL and 2.20 ug/dL at 30 and 60 mins post ACTH respectively. A Chest xray showed   PTB with cavitary lesion. He was given Hydrocortisone 30mg/day and Fludrocortisone 0.1mg/day.

 Since test for adrenal autoantibodies are not available in the Philippines, information obtained by CT scan is important in the etiological diagnosis of Addison’s disease. A CT scan of the abdomen with IV contrast showed the adrenals are small   with the right measuring approximately 2cm in length and the left measuring 3 cm in length. No focal lesions, no abnormal enhancement or calcification seen.  Studies show that  patients with active pulmonary tuberculosis did not show evidence of adrenal cortical insufficiency (York, 1992, Barnes,1989). Kelestimur  evaluated  radiological findings of PTB  patients and the size of adrenal glands on CT scan. He observed that adrenal glands are enlarged on CT scan while small glands generally indicate either idiopathic atrophy or long-standing tuberculosis (Kelestimur, 1994).  Standard TB therapy includes Rifampicin a potent hepatic enzyme inducer that contribute to adrenal insufficiency by accelerating the catabolism of cortisol. (Venter, 2006).

Conclusion: While some of the studies showed normalization of the adrenal function following treatment of anti-TB drugs  others have contradicted it. In this case, both adrenal glands are small.  It is prudent to re-evaluate this patient if there is recovery of adrenal function upon completion of anti-TB treatment. Close follow up is required to prevent an adrenal crisis.

(1.)Kelestimur, F., Unlu, Yalcin. A hormonal and radiological evaluation of adrenal gland in patients with acute or chronic pulmonary tuberculosis. Clinical Endocrinology (1994) 41, 53-56.

 

Nothing to Disclose: PA