Bilateral adrenal histoplasmosis in an immunocompetent man from Texas

Adrenal Histoplasmosis and Tuberculosis: Clinical Presentations and a High Prevalence of Adrenal Insufficiency

OBJECTIVE

Adrenal infections can lead to adrenal insufficiency (AI). Commonly reported pathogens are Histoplasma capsulatum and Mycobacterium tuberculosis (TB), which can cause similar clinical presentations, yet require different specific treatments. We aim to evaluate clinical presentations, imaging characteristics, and AI prevalence in adrenal infections caused by these pathogens.

DESIGNS

Retrospective study.

PATIENTS

Thirty-five patients with microbiologically confirmed adrenal histoplasmosis and TB at two referral centers in Bangkok, Thailand.

RESULTS

Thirty-one patients (88.5%) had adrenal histoplasmosis, 3 (8.5%) had adrenal TB, and 1 (3.0%) had coinfection. Most patients were non-HIV (97%) males (91%), with a mean age of 64 years. Common symptoms were anorexia and weight loss (91%), with 26% presenting with adrenal crisis. Extra-adrenal infections occurred in 45% of histoplasmosis, 67% of TB, and 100% of coinfections, with 10% of adrenal histoplasmosis patients having concurrent extra-adrenal TB infection. Bilateral adrenal abnormalities were seen in 91%, and all patients with unilateral lesions later developed contralateral involvement. Adrenal lesions ranged from enlargement to mass sized 9.8 cm. The prevalence of AI was 74% (histoplasmosis 73%, TB and coinfection 100%). Over a median follow-up of 22 months, all patients with AI remained on glucocorticoid supplements.

CONCLUSION

Adrenal histoplasmosis and TB primarily affected non-HIV males. Most patients presented with bilateral adrenal masses. The prevalence of AI was high and likely persistent despite specific treatment. Extra-adrenal infections were common in TB and coinfection but were insufficient to determine adrenal infection etiology, highlighting the need for tissue diagnosis.

Disseminated histoplasmosis presenting as adrenal insufficiency: A case report

This report aims to highlight rarity of disseminated histoplasmosis (DH) presenting as adrenal insufficiency and the need for considering it in the differential diagnosis, even in non-endemic areas. A case is presented of a 69-year-old male patient with a background of hypertension and diabetes mellitus, with a persistent fever, significant loss of weight, and general weakness. Imaging studies showed adrenal masses in both adrenal glands, and laboratory tests showed hyperkalemia and hyponatremia. Hormonal tests confirmed the diagnosis of adrenal insufficiency. CT-guided adrenal biopsy confirmed the diagnosis of histoplasmosis. The patient received a 14-day course of Amphotericin B, followed by oral Itraconazole and glucocorticoid substitution therapy, with improvement in adrenal function over a period of time.

Disseminated adrenal histoplasmosis in an immunocompetent adult from Nepal: a case report

Introduction

Histoplasmosis is caused by the environmental fungus Histoplasma capsulatum. In immunocompromised patients, histoplasmosis can present as a disseminated infection that can involve the liver, lymph nodes, lungs, and adrenal glands. Disseminated histoplasmosis affecting the adrenal glands in an immunocompetent individual is a rare infection.

Case presentation

A 53-year-old male without HIV complained of weight loss of 15 kg in 6 months. Computed tomography (CT) scan of the abdomen was done, which showed bilateral adrenal gland hyperplasia with hepatosplenomegaly. Endoscopic ultrasound fine needle aspiration of the adrenal gland revealed numerous budding yeast forms of Histoplasma intracellularly within the macrophages. A diagnosis of disseminated adrenal histoplasmosis was made. Liposomal amphotericin B and itraconazole therapy was started.

Discussion

Disseminated histoplasmosis is commonly present in immunocompromised individuals. Immunocompetent individuals may also present with the disseminated form of the disease, which typically involves the adrenal glands. CT scan of the abdomen shows bulky adrenal glands with normal configuration, peripheral enhancement, and central hypodensities due to necrosis and/or hemorrhage. This might be a common presentation in other disseminated infections. Therefore, a definitive visualization of H. capsulatum in tissue specimens is the best method to confirm the diagnosis in a patient.

Conclusion

Physicians must be suspicious of disseminated adrenal histoplasmosis in patients presenting with enlarged adrenal glands, even in immunocompetent individuals who are from endemic regions. Histopathological or cytological evaluation is the best method to establish a diagnosis.

Adrenal Abscesses: A Systematic Review of the Literature

Objective: To summarize the existing knowledge about adrenal gland abscesses, including etiology, clinical presentation, common laboratory and imaging findings, management and overall morbidity and mortality. Design: Systematic literature review. Methods: We performed a search in the PubMed database using search terms: 'abscess and adrenal glands', 'adrenalitis', 'infection and adrenal gland', 'adrenal abscess', 'adrenal infection' and 'infectious adrenalitis'. Articles from 2017 to 2022 were included. We found total of 116 articles, and after applying exclusion criteria, data from 73 articles was included in the final statistical analysis. Results: Of 84 patients included in this review, 68 were male (81%), with a mean age of 55 years (range: 29 to 85 years). Weight loss was the most frequent symptom reported in 58.3% patients, followed by fever in 49%. Mean duration of symptoms was 4.5 months. The most common laboratory findings were low cortisol (51.9%), elevated ACTH (43.2%), hyponatremia (88.2%) and anemia (83.3%). Adrenal cultures were positive in 86.4% cases, with Histoplasma capsulatum (37.3%) being the leading causative agent. Blood cultures were positive in 30% of patients. The majority of the adrenal infections occurred through secondary dissemination from other infectious foci and abscesses were more commonly bilateral (70%). A total of 46.4% of patients developed long-term adrenal insufficiency requiring treatment. Abscess drainage was performed in 7 patients (8.3%) and adrenalectomy was performed in 18 (21.4%) patients. The survival rate was 92.9%. Multivariate analysis showed that the only independent risk factor for mortality was thrombocytopenia (p = 0.048). Conclusion: Our review shows that adrenal abscesses are usually caused by fungal pathogens, and among these, Histoplasma capsulatum is the most common. The adrenal glands are usually involved in a bilateral fashion and become infected through dissemination from other primary sources of infection. Long-term adrenal insufficiency develops in 46% of patients, which is more common than what is observed in non-infectious etiology of adrenal gland disorders. Mortality is about 7%, and the presence of thrombocytopenia is associated with worse prognosis. Further prospective studies are needed to better characterize optimal testing and treatment duration in patients with this relatively rare but challenging disorder.

Bilateral adrenal histoplasmosis presenting as adrenal mass mimicking malignancy in an immunocompetent patient

We report a case of a 78-year-old immunocompetent man who presented with worsening fatigue and lethargy for one month. He had also been complaining of cough and SOB for two months which had been attributed to his underlying COPD and possible pneumonia. CT showed bilateral pleural effusions, ground-glass opacities, cirrhosis, splenomegaly and bilateral adrenal masses which was highly suspicious for malignancy. After pheochromocytoma was ruled out, EUS-FNA guided biopsy was performed on the left adrenal gland. Histology was positive for yeast cells, with fungal staining (PAS) revealing narrow-based budding compatible with Histoplasma. The patient was treated with amphotericin and itraconazole. Our case is unique as he presented with hepatosplenomegaly, which is reported in less than a quarter of cases. Although typically a diagnosis in immunocompromised patients, a high index of clinical suspicion is required to diagnose disseminated histoplasmosis in an immunocompetent patient. The gold standard for diagnosis is fungal tissue culture. However results may take up to weeks. EUS-FNA guided biopsy of adrenal glands can aid in early definitive diagnosis and management.

A Case of Disseminated Histoplasmosis From California, in the Setting of Secondary Hemophagocytic Lymphohistiocytosis: A Diagnostic Challenge

Histoplasma capsulatum is a geographically specific dimorphic fungus that can cause a spectrum of diseases. While most cases are asymptomatic pulmonary infections, in severe cases, particularly in immunocompromised patients, disseminated disease can occur. Histoplasmosis in California is limited to only a few case reports. In this article, we describe a rare case of disseminated histoplasmosis in a non-endemic region presenting with diagnostically challenging symptomatology, including altered mental status, status epilepticus, septic shock, and bilateral adrenal masses.

Histoplasmosis: An Unusual Cause of Adrenal Insufficiency

Objective

Adrenal insufficiency (AI), if not diagnosed in a timely manner, can lead to fatal outcomes. Here we describe an unusual case of AI secondary to disseminated histoplasmosis (DH) and the importance of being aware of the association of infections and AI.

Methods

A 56-year-old Hispanic man with untreated HIV infection presented for the evaluation of left upper jaw swelling and pain. A brain magnetic resonance imaging scan revealed a 4-cm soft-tissue mass in the left maxilla. Biopsy of the mass was consistent with histoplasmosis. He was also noted to have hyponatremia and hyperkalemia, which raised the suspicion of AI. Laboratory investigation showed a baseline cortisol level of 7 μg/dL (normal, 7-23 μg/dL) and adrenocorticotropic hormone level of 86 pg/mL (normal, 7-69 pg/mL). His 60-minute cortisol level after a 250-μg cosyntropin stimulation test was 9 μg/dL (normal, 7-23 μg/dL). Computed tomography of the chest incidentally noted bilateral adrenal enlargement. An adrenal biopsy was not pursued due to the high index of clinical suspicion of DH as the etiology of AI.

Results

He was diagnosed with adrenal histoplasmosis because of the evidence of AI and bilateral adrenal enlargement in the setting of DH. He was started on glucocorticoid replacement for primary AI and continues to be on glucocorticoids even after 5 years of diagnosis. DH frequently involves the adrenal gland (80%) and can present as adrenal enlargement but does not always cause primary AI.

Conclusion

Our case demonstrates the importance of being vigilant about infections like histoplasmosis as a potential cause of AI. Delay in treatment in such cases could result in life-threatening consequences.

A Rare Presentation of Possible Disseminated Histoplasmosis with Adrenal Insufficiency Leading to Adrenal Crisis in an Immunocompetent Adult: A Case Report

Histoplasmosis is caused by Histoplasma capsulatum, and commonly it causes an asymptomatic illness. Although Histoplasma is the commonest organism to infect adrenal glands, disseminated histoplasmosis in an immune-competent host leading to adrenal insufficiency is rare in current literature. Here, we report a case of possible disseminated histoplasmosis leading to adrenal crisis in a young Asian immunocompetent male. A 42-year-old Sri Lankan male with noninsulin-dependent diabetes mellitus presented with constitutional symptoms and feverishness for three weeks' duration. He was found to have hepatosplenomegaly with bilateral adrenal masses and pancytopenia. One week later, he developed severe vomiting and hemodynamic collapse and was found to have suppressed adrenal functions. Ultrasound-guided biopsy of adrenals showed fungal spores morphologically similar to Histoplasma. He was started on oral itraconazole and adrenal replacement therapy. He improved symptomatically with treatment and currently is on regular clinic follow-up with a plan to continue antifungal therapy for at least one year to prevent a relapse. Fungal infections, especially histoplasmosis, need to be considered in all immunocompetent patients with compatible history and bilateral adrenal masses. Adrenal insufficiency needs to be promptly diagnosed and treated to prevent Addisonian crisis in these patients.

Disseminated histoplasmosis in immunocompetent patients from an arid zone in Western India: A case series

Histoplasmosis is a systemic fungal disease caused by dimorphic fungus Histoplasma capsulatum and is more common in immunocompromised patients. We report two cases of disseminated histoplasmosis in immunocompetent individuals from a non-endemic zone in Western India. Rapid diagnostic tests like urinary antigen detection and molecular assays comprise the need of the hour as early initiation of antifungal therapy can be life-saving. Clinicians need to be aware of this entity to prevent misdiagnosis and initiate prompt effective management.

A challenging case of pyrexia of unknown origin: adrenal histoplasmosis mimicking tuberculosis in a patient with chronic hepatitis C

We present an unusual case of fever of unknown origin with bilateral adrenal masses in a patient with compensated chronic liver disease (compensated) due to hepatitis C who had been treated elsewhere with four months of anti-tuberculous therapy for suspected disseminated tuberculosis (TB). At our institution, he underwent a CT-guided biopsy of the adrenal lesion which to our surprise did not reveal any evidence of TB but a close mimic.

MANAGEMENT OF ENDOCRINE DISEASE: Differential diagnosis, investigation and therapy of bilateral adrenal incidentalomas

The investigation and management of unilateral adrenal incidentalomas have been extensively considered in the last decades. While bilateral adrenal incidentalomas represent about 15% of adrenal incidentalomas (AIs), they have been less frequently discussed. The differential diagnosis of bilateral incidentalomas includes metastasis, primary bilateral macronodular adrenal hyperplasia and bilateral cortical adenomas. Less frequent etiologies are bilateral pheochromocytomas, congenital adrenal hyperplasia (CAH), Cushing's disease or ectopic ACTH secretion with secondary bilateral adrenal hyperplasia, primary malignancies, myelolipomas, infections or hemorrhage. The investigation of bilateral incidentalomas includes the same hormonal evaluation to exclude excess hormone secretion as recommended in unilateral AI, but diagnosis of CAH and adrenal insufficiency should also be excluded. This review is focused on the differential diagnosis, investigation and treatment of bilateral AIs.