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Moon G, Nadeem M, Usiukiewicz S, Jamil M, Idrisov E, Sawh R, Weston A. Bilateral adrenal histoplasmosis presenting as adrenal mass mimicking malignancy in an immunocompetent patient. IDCases 2023; 32:e01803. [PMID: 37250375 PMCID: PMC10209802 DOI: 10.1016/j.idcr.2023.e01803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 05/15/2023] [Accepted: 05/16/2023] [Indexed: 05/31/2023] Open
Abstract
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.
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Affiliation(s)
- Gina Moon
- Department of Internal Medicine, University of Oklahoma Health Sciences Center, 800 Stanton L Young Blvd, Oklahoma City, OK 73117, USA
| | - Mahum Nadeem
- Department of Internal Medicine, University of Oklahoma Health Sciences Center, 800 Stanton L Young Blvd, Oklahoma City, OK 73117, USA
| | - Shana Usiukiewicz
- Department of Internal Medicine, University of Oklahoma Health Sciences Center, 800 Stanton L Young Blvd, Oklahoma City, OK 73117, USA
| | - Mohammad Jamil
- Department of Internal Medicine, University of Oklahoma Health Sciences Center, 800 Stanton L Young Blvd, Oklahoma City, OK 73117, USA
| | - Evgeny Idrisov
- Department of Digestive Diseases and Nutrition, Oklahoma City VA Health Care System, 921 NE 13th St, Oklahoma City, OK 73104, USA
| | - Ravindranauth Sawh
- Department of Pathology, Oklahoma City VA Health Care System, 921 NE 13th St, Oklahoma City, OK 73104, USA
| | - Allan Weston
- Department of Digestive Diseases and Nutrition, Oklahoma City VA Health Care System, 921 NE 13th St, Oklahoma City, OK 73104, USA
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Bhattacharyya K, Pal S, Dutta A, Bhattachryya PP, Laskar S. Histoplasmosis of Adrenal Gland: A 5 Years' Review from a Multispecialty Diagnostic Centre. J Lab Physicians 2022. [DOI: 10.1055/s-0042-1757587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Abstract
Objective Histoplasmosis is an infectious disease caused by the dimorphic fungus Histoplasma capsulatum. Histoplasmosis is considered to be endemic to India, especially the Gangetic belt. Disseminated histoplasmosis may affect almost all systems. Disseminated histoplasmosis with asymptomatic adrenal involvement has been described in immunocompromised patients, whereas isolated adrenal involvement as the presenting manifestation in immunocompetent is uncommon. We aimed to determine the clinicopathological and radiological findings of adrenal histoplasmosis in immunocompetent patients attending a multispecialty diagnostic center referred from different clinics and hospitals.
Materials and Methods All tissue samples were initially examined microscopically by performing potassium hydroxide (KOH) wet mounts, followed by culture on two tubes of Sabouraud dextrose agar and phase conversion. Histopathological correlation was done using tissue stains, hematoxylin and eosin, periodic acid–Schiff, and Gomori methenamine silver.
Results We evaluated 84 clinically suspected cases radiologically for adrenal mass. The pathological and microbiological work-up was done from these suspected cases. A total of 19 cases were evident from the tissue stain and fungal culture methods. The affected population were mostly above 45 years and male. Seven patients had bilateral adrenal involvement. All these patients received amphotericin B and/or itraconazole treatment, which led to symptomatic improvement in most cases.
Conclusion Diagnosis of invasive fungal infection requires a high index of suspicion, especially in immunocompetent patients presenting with nonspecific symptoms, clinical signs, and laboratory and radiological features that often resemble adrenal neoplasms. Clinical specimens, together with fungal culture, must be sent for cytopathology/histopathology for a definite diagnosis and appropriate management.
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Affiliation(s)
- Kumkum Bhattacharyya
- Department of Microbiology, Quadra Medical Services, Kolkata, West Bengal, India
- Department of Microbiology, Institute of Post Graduate Medcal Education & Research, Kolkata, West Bengal, India
| | - Suranjan Pal
- Department of Microbiology, Raiganj Government Medical College, Raiganj, Uttar Dinajpur, West Bengal, India
| | - Ashis Dutta
- Department of Pathology, Quadra Medical Services, Kolkata, West Bengal, India
| | | | - Saurabh Laskar
- Department of Microbiology, Quadra Medical Services, Kolkata, West Bengal, India
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Pal N, Banu HN, Chakraborty M, Jain N, Maiti PK. Current perspective of adrenal histoplasmosis in India: A prospective study in a tertiary care hospital, Eastern India. Indian J Med Microbiol 2022; 43:90-95. [PMID: 36272878 DOI: 10.1016/j.ijmmb.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 09/22/2022] [Accepted: 10/03/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE Adrenal histoplasmosis (AH) is an uncommon form of disseminated histoplasmosis caused by the dimorphic fungus Histoplasma capsulatum. Though, India is considered to be a non-endemic area for histoplasmosis, a high rise of AH cases is reported currently from various parts of India. Our study aimed to evaluate the current perspective of adrenal histoplasmosis in India by reviewing its clinical course, differential diagnosis, treatment, and mortality of our eleven confirmed cases of AH along with the review of authentic reported AH cases from India. MATERIAL &METHOD Clinical materials were taken from radiologically suspected all 15 cases either with unilateral or bilateral adrenal enlargement, referred between 2018 and 2020 for microbiological investigations. Fungal stain and fungal culture along with other tests for possible differential diagnosis with AH were conducted. RESULT Out of fifteen incidentaloma detected by radio-imaging, eleven cases of AH had been diagnosed in our hospital with yield of Rhodotorula spp. in one mimicking case. Nine of them were male (82%) and all were HIV nonreactive, which corroborates with the literature review. All of them had nonspecific clinical presentation of chronic abdominal pain, fever, weight loss, and anorexia. Four developed primary adrenal insufficiency, which are similar to the literature review (41%). On treatment with itraconazole and/or amphotericin B, all patients survived except one lost in follow-up. CONCLUSION Male preponderance and non-compromised immune status are two special characteristics of most AH though reasons are ill understood. So, mycological investigations are to be done for every such case.
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Affiliation(s)
- Nupur Pal
- Department of Microbiology, Institute of Post-Graduate Medical Education & Research, 244 AJC Bose Road, Kolkata 700020, India.
| | - Hossain Najma Banu
- Department of Microbiology, Institute of Post-Graduate Medical Education & Research, 244 AJC Bose Road, Kolkata 700020, India
| | - Mohana Chakraborty
- Department of Microbiology, Institute of Post-Graduate Medical Education & Research, 244 AJC Bose Road, Kolkata 700020, India
| | - Namrata Jain
- Department of Microbiology, Institute of Post-Graduate Medical Education & Research, 244 AJC Bose Road, Kolkata 700020, India
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Hussain A, Cherian KE, Kapoor N, Prabhu AJ, Paul TV. Adrenal Histoplasmosis-A Therapeutic Restoration of Adrenal Morphology. AACE Clin Case Rep 2022; 8:45-46. [PMID: 35097203 PMCID: PMC8784714 DOI: 10.1016/j.aace.2021.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 03/16/2021] [Accepted: 03/16/2021] [Indexed: 11/06/2022] Open
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Teng Q, Fan B, Wang Y, Wen S, Wang H, Liu T, Wang L. Primary adrenal tuberculosis infection in patients with Behcet's disease presenting as isolated adrenal metastasis by 18F-FDG PET/CT: a rare case report and literature review. Gland Surg 2021; 10:3431-3442. [PMID: 35070903 PMCID: PMC8749099 DOI: 10.21037/gs-21-511] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 11/05/2021] [Indexed: 07/30/2023]
Abstract
Primary adrenal tuberculosis (TB) is a rare type of extrapulmonary tuberculosis (EPTB). A pathological biopsy is usually required to make a definite diagnosis due to nonspecific symptoms. Antituberculous chemotherapy is the main treatment regimen, and cortisol replacement therapy should be added when adrenal insufficiency is involved. Here, we present a 59-year-old man who had recurrence of oral and genital aphthosis for 3 years and was diagnosed with Behcet's disease (BD), which was cured by thalidomide. After 10 days of admission, the patient had sudden abdominal pain in the right upper quadrant with high fever and was diagnosed with acute cholecystitis attack, which was treated by percutaneous transhepatic gallbladder drainage (PTGBD). Further contrast-enhanced CT showed a right adrenal mass with a diameter of 2.0 cm, and PET-CT indicated intense 18F-fluorodeoxyglucose (18F-FDG) uptake in the right adrenal mass with a maximum standardized uptake value (SUVmax) of 15.2. As a metastatic adrenal mass was suspected, the patient underwent retroperitoneal laparoscopic adrenalectomy. Histopathological and immunohistochemical analysis revealed primary adrenal TB. After routine anti-tuberculosis treatment with isoniazid, rifampin, pyrazinamide and ethambutol for six months, the patient was cured and discharged. In summary, primary unilateral adrenal TB without adrenal insufficiency is difficult to diagnose only on the basis of clinical manifestations and examinations. Further studies are needed to develop an easier and more accurate diagnostic examination.
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Affiliation(s)
- Qiliang Teng
- Department of Urology, Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Bo Fan
- Department of Urology, Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yutong Wang
- First Clinical College, Dalian Medical University, Dalian, China
| | - Shuang Wen
- Department of Pathology, Dalian Friendship Hospital, Dalian, China
| | - Honglong Wang
- Department of Pathology, Dalian Friendship Hospital, Dalian, China
| | - Tianqing Liu
- Department of Pathology, Dalian Friendship Hospital, Dalian, China
| | - Liang Wang
- Department of Urology, Second Affiliated Hospital of Dalian Medical University, Dalian, China
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Banerjee S, Denning DW, Chakrabarti A. One Health aspects & priority roadmap for fungal diseases : A mini-review. Indian J Med Res 2021; 153:311-319. [PMID: 33906993 PMCID: PMC8204821 DOI: 10.4103/ijmr.ijmr_768_21] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Indexed: 11/29/2022] Open
Abstract
Fungal diseases have not been taken seriously in public health agendas as well as research priorities, despite of globally causing an estimated two million deaths every year, and the emergence of many troublesome fungal pathogens like Candida auris, azole resistant Aspergillus fumigatus, terbinafine and azole resistant dermatophytes, and zoonotic sporotrichosis in humans. Fungi are also responsible for huge losses of agricultural products and stored crops as well as recent massive and unexpected mortality in animals caused by white-nose syndrome in the bats and Chytridiomycosis in amphibians. This review aims to underscore the need for collaborative, multisectoral, and trans-disciplinary approach to include the One Health approach as an essential component of surveillance, prevention, and control of globally emerging fungal diseases. Rigorous evidence based surveillance of the environment as well as strengthening rapid and quality diagnosis of fungal diseases can save millions of lives and reduce significant morbidity.
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Affiliation(s)
- Sayantan Banerjee
- Department of Infectious Diseases, Beleghata Infectious Diseases & BG Hospitals, Beleghata, Kolkata, West Bengal, India
| | - David W. Denning
- Manchester Fungal Infection Group, Faculty of Biology, Medicine and Health, The University of Manchester, United Kingdom
- Global Action Fund for Fungal Infections, Geneva, Switzerland
| | - Arunaloke Chakrabarti
- Department of Medical Microbiology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
- Center of Advanced Research in Medical Mycology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
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Jahan S, Mahmood T, Fariduddin M, Faisal I, Morshed M, Yadav A, Shah A, Abdullah C, Chowdhury EUR, Begum F, Hasanat MA. Clinical, biochemical and imaging characteristics of adrenal histoplasmosis in immunocompetent patients in a non-endemic area: A case series. ASIAN PAC J TROP MED 2021. [DOI: 10.4103/1995-7645.326256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Nepal P, Ojili V, Tirumani SH, Gunabushanam G, Nagar A. A pictorial review of non-traumatic adrenergic crisis. Emerg Radiol 2020; 27:533-545. [PMID: 32300900 DOI: 10.1007/s10140-020-01777-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 04/01/2020] [Indexed: 10/23/2022]
Abstract
Non-traumatic adrenal crisis is a rare but critical diagnosis to make in emergency settings due to grave consequences. Various pathologies can present as acute crisis, such as spectrum of endocrine imbalance, ranging from catecholamine excess in pheochromocytomas to acute adrenal insufficiency related to glandular dysfunction. Critical manifestations may be due to structural causes related to adrenal hemorrhage, especially when they are bilateral. Oncological complications such as vascular invasion, tumoral bleed, rupture, and hormonal dysfunction can occur. Due to non-specific clinical presentation, these conditions may come as a surprise on imaging performed for other reasons. Recognition of these imaging findings is critical for appropriate patient management. Although there are few articles discussing non-traumatic emergencies in literature, this review is inclusive of all possible etiologies, thus provides a holistic approach and insight into each situation. Specific imaging approach is needed to tailor the diagnosis. This article will also discuss about the advanced imaging techniques that will complement diagnosis.
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Affiliation(s)
- Pankaj Nepal
- St. Vincent's Medical Center, Bridgeport, CT, USA
| | | | - Sree Harsha Tirumani
- University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | | | - Arpit Nagar
- Ohio State University Wexner Medical Center, Columbus, OH, USA
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Agrawal S, Goyal A, Agarwal S, Khadgawat R. Hypercalcaemia, adrenal insufficiency and bilateral adrenal histoplasmosis in a middle-aged man: a diagnostic dilemma. BMJ Case Rep 2019; 12:12/8/e231142. [PMID: 31466957 DOI: 10.1136/bcr-2019-231142] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
A 45-year-old man presented with a 3-month history of involuntary weight loss, anorexia, postural dizziness and intermittent fever. On investigation, he was found to have parathyroid hormone (PTH)-independent hypercalcaemia, with negative workup for 25-hydroxyvitamin D or 1,25-dihydroxyvitamin D excess, thyrotoxicosis, multiple myeloma and bony metastases. On further evaluation, he was detected to have primary hypoadrenalism with bilateral adrenal enlargement, secondary to adrenal histoplasmosis. Hypercalcaemia improved with hydration and physiological steroid replacement even before initiation of antifungal therapy, confirming adrenal insufficiency as the cause for hypercalcaemia. Hypercalcaemia resulting from hypoadrenalism secondary to adrenal histoplasmosis is rare and should be suspected whenever evaluating a patient with PTH-independent hypercalcaemia.
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Affiliation(s)
| | - Alpesh Goyal
- Endocrinology, All India Institute of Medical Sciences, New Delhi, India
| | - Shipra Agarwal
- Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Rajesh Khadgawat
- Endocrinology, All India Institute of Medical Sciences, New Delhi, India
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Alshahrani MA, Bin Saeedan M, Alkhunaizan T, Aljohani IM, Azzumeea FM. Bilateral adrenal abnormalities: imaging review of different entities. Abdom Radiol (NY) 2019; 44:154-179. [PMID: 29938331 DOI: 10.1007/s00261-018-1670-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Bilateral adrenal abnormalities are not infrequently encountered during routine daily radiology practice. The differential diagnoses of bilateral adrenal abnormalities include neoplastic and non-neoplastic entities. The bilateral adrenal tumors include metastasis, lymphoma, neuroblastoma, pheochromocytoma, adenoma, and myelolipoma. Non-neoplastic bilateral adrenal masses include infectious processes and haematomas. There are different diffuse bilateral adrenal changes such as adrenal atrophy, adrenal enlargement, adrenal calcifications, and altered adrenal enhancement. In this pictorial review article, we will discuss the imaging features of these entities with emphasis on their clinical implications.
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Affiliation(s)
- Meshal Ali Alshahrani
- Department of Radiology, King Faisal Specialist Hospital and Research Center, MBC-28, P.O. Box 3354, Riyadh, 11211, Saudi Arabia
| | - Mnahi Bin Saeedan
- Department of Radiology, King Faisal Specialist Hospital and Research Center, MBC-28, P.O. Box 3354, Riyadh, 11211, Saudi Arabia.
| | - Tariq Alkhunaizan
- Department of Radiology, King Faisal Specialist Hospital and Research Center, MBC-28, P.O. Box 3354, Riyadh, 11211, Saudi Arabia
| | - Ibtisam Musallam Aljohani
- Department of Radiology, King Faisal Specialist Hospital and Research Center, MBC-28, P.O. Box 3354, Riyadh, 11211, Saudi Arabia
| | - Fahad Mohammed Azzumeea
- National Guard Health Affairs, King Abdulaziz Medical City, Medical Imaging Department, Riyadh, Saudi Arabia
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Abstract
An 89-year-old woman presented with seizure and hyponatremia. CT and MRI demonstrated mass-like enlargement of the adrenal glands and multiple pulmonary nodules. PET/CT performed to evaluate for metastatic disease demonstrated intense F-FDG uptake within enlarged adrenal glands. Given mild uptake in the pulmonary nodules, the differential diagnosis for the adrenal uptake included lymphoma, granulomatous infection, and less likely, metastatic lung cancer.
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Gupta A, Ghosh A, Singh G, Xess I. A Twenty-First-Century Perspective of Disseminated Histoplasmosis in India: Literature Review and Retrospective Analysis of Published and Unpublished Cases at a Tertiary Care Hospital in North India. Mycopathologia 2017; 182:1077-1093. [PMID: 29080114 DOI: 10.1007/s11046-017-0191-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Accepted: 08/08/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE Published literature lacks systematic studies on disseminated histoplasmosis in India, and previous reviews on its epidemiology in India were conducted two decades back. Thus, we review the Indian studies published in this century to understand the recent epidemiology of histoplasmosis in India and do a retrospective analysis of all cases diagnosed at our institute. METHODS A literature of review search was done in Pubmed/Medline and Scopus. Studies published during January 2001-December 2015 were considered along with retrospective analysis of cases presented to us. A distinction was made in the clinical presentation of immunocompetent and immunocompromised cases. RESULTS Ninety-five included studies described 204 cases, and 10 cases from our retrospective analysis were included. The mean age at presentation was 45.1 ± 15.4 years [range 3-83, median 45, interquartile range 37-55], and male-to-female ratio was 6:1. Most cases were reported from northern and northeastern states of India along the rivers Ganges, Yamuna and Brahmaputra and in people associated with agricultural activity. About 33% of cases were immunocompromised, out of which immunosuppression due to HIV was seen in 72% cases. The mean age of presentation was significantly lower in immunocompromised cases (37.9 vs. 49.2 years; p < 0.00001, Mann-Whitney test), and mortality was also higher (10 vs. 27.5%, p = 0.01, Fisher's exact test). Adrenal involvement was in significantly higher proportion of immunocompetent patients compared to immunocompromised population. CONCLUSIONS Disseminated histoplasmosis is being increasingly recognized in India. There is a need to undertake well-designed, analytical studies utilizing appropriate diagnostic modalities to understand the epidemiology of this neglected disease in proper perspective.
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Affiliation(s)
- Ayush Gupta
- Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India
| | - Arnab Ghosh
- Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India
| | - Gagandeep Singh
- Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India
| | - Immaculata Xess
- Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India.
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Orlowski HLP, McWilliams S, Mellnick VM, Bhalla S, Lubner MG, Pickhardt PJ, Menias CO. Imaging Spectrum of Invasive Fungal and Fungal-like Infections. Radiographics 2017. [PMID: 28622118 DOI: 10.1148/rg.2017160110] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Invasive fungal and fungal-like infections contribute to substantial morbidity and mortality in immunocompromised individuals. The incidence of these infections is increasing-largely because of rising numbers of immunocompromised patients, including those with neutropenia, human immunodeficiency virus, chronic immunosuppression, indwelling prostheses, burns, and diabetes mellitus, and those taking broad-spectrum antibiotics. Invasive fungal pathogens include primary mycotic organisms such as Histoplasma capsulatum, Coccidioides immitis, Blastomyces dermatitidis, and Paracoccidioides brasiliensis, which are true pathogens and inherently virulent. Secondary mycotic organisms such as Candida and Aspergillus species, Cryptococcus neoformans, Pneumocystis jirovecii, and Mucorales fungi are opportunistic, less virulent pathogens. Nocardia and Actinomyces species are gram-positive bacteria that behave like fungi in terms of their growth pattern and cause fungal-like invasive indolent infections; thus, these organisms are included in this review. Fungal and fungal-like infections can affect a variety of organ systems and include conditions such as meningitis, sinusitis, osteomyelitis, and enteritis. As awareness of these infections increases, timely diagnosis and treatment will become even more important. Imaging has a critical role in the evaluation of disease activity, therapy response, and related complications. Using an organ-based approach with computed tomography, magnetic resonance imaging, and ultrasonography to gain familiarity with the appearances of these infections enables timely and accurate diagnoses. ©RSNA, 2017.
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Affiliation(s)
- Hilary L P Orlowski
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S Kingshighway Blvd, Box 8131, St Louis, MO 63110 (H.L.P.O., S.M., V.M.M., S.B.); Department of Radiology, University of Wisconsin, Madison, Wis (M.G.L., P.J.P.); and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.O.M.)
| | - Sebastian McWilliams
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S Kingshighway Blvd, Box 8131, St Louis, MO 63110 (H.L.P.O., S.M., V.M.M., S.B.); Department of Radiology, University of Wisconsin, Madison, Wis (M.G.L., P.J.P.); and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.O.M.)
| | - Vincent M Mellnick
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S Kingshighway Blvd, Box 8131, St Louis, MO 63110 (H.L.P.O., S.M., V.M.M., S.B.); Department of Radiology, University of Wisconsin, Madison, Wis (M.G.L., P.J.P.); and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.O.M.)
| | - Sanjeev Bhalla
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S Kingshighway Blvd, Box 8131, St Louis, MO 63110 (H.L.P.O., S.M., V.M.M., S.B.); Department of Radiology, University of Wisconsin, Madison, Wis (M.G.L., P.J.P.); and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.O.M.)
| | - Meghan G Lubner
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S Kingshighway Blvd, Box 8131, St Louis, MO 63110 (H.L.P.O., S.M., V.M.M., S.B.); Department of Radiology, University of Wisconsin, Madison, Wis (M.G.L., P.J.P.); and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.O.M.)
| | - Perry J Pickhardt
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S Kingshighway Blvd, Box 8131, St Louis, MO 63110 (H.L.P.O., S.M., V.M.M., S.B.); Department of Radiology, University of Wisconsin, Madison, Wis (M.G.L., P.J.P.); and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.O.M.)
| | - Christine O Menias
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S Kingshighway Blvd, Box 8131, St Louis, MO 63110 (H.L.P.O., S.M., V.M.M., S.B.); Department of Radiology, University of Wisconsin, Madison, Wis (M.G.L., P.J.P.); and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.O.M.)
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Grover S, Selhi PK, Sood N, Sood R, Kaur H. "Polka Dot Macrophages" on cytology of bilateral adrenal masses-Nailing disseminated histoplasmosis. Diagn Cytopathol 2017; 45:943-946. [PMID: 28548709 DOI: 10.1002/dc.23758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 04/20/2017] [Accepted: 05/08/2017] [Indexed: 11/06/2022]
Abstract
Histoplasma capsulatum is a saprophytic fungus that in immunocompetent individuals causes self-limited pulmonary infection; however, in immunosuppressed patients involvement of the reticuloendothelial system, alimentary tract, urinary tract, and central nervous system is fairly common. Rarely patients present with bilateral adrenal masses which mimic tuberculosis and metastasis on radiology because of associated central necrosis. Ultrasound guided FNAC aided by special stains like Periodic Acid Schiff (PAS) and Gomori Methenamine Silver (GMS) may help in early diagnosis in such dubious cases. Polka dot macrophages were the clue to diagnosis of histoplasmosis on toluidine blue rapid staining, Hematoxylin & Eosin, and Pap stained smears. We report this case because of its rarity, diagnostic difficulty on radiology, and rapidity of diagnosis by FNA due of its characteristic cytomorphology.
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Affiliation(s)
- Sumit Grover
- Department of Pathology, Dayanand Medical College & Hospital, Ludhiana, Punjab, India
| | - Pavneet Kaur Selhi
- Department of Pathology, Dayanand Medical College & Hospital, Ludhiana, Punjab, India
| | - Neena Sood
- Department of Pathology, Dayanand Medical College & Hospital, Ludhiana, Punjab, India
| | - Ridhi Sood
- Department of Pathology, Dayanand Medical College & Hospital, Ludhiana, Punjab, India
| | - Harpreet Kaur
- Department of Pathology, Dayanand Medical College & Hospital, Ludhiana, Punjab, India
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Abstract
With increasing numbers of travelers and immunocompromised patients, histoplasmosis, caused by the dimorphic fungus Histoplasma capsulatum, has become a disease of national extent. The clinical spectrum of histoplasmosis is very wide, in terms of disease cadence, onset, distribution, and severity. A multipronged approach is recommended for diagnosis. Manifestations that are always treated include moderate to severe acute pulmonary histoplasmosis, disseminated disease, and histoplasmosis in immunocompromised individuals. Amphotericin B is the drug of choice for moderate to severe and disseminated presentations, whereas itraconazole is appropriate for mild disease and as step-down therapy.
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Kumar R, Dey P. Fine-needle aspiration cytology of non-neoplastic adrenal pathology. Diagn Cytopathol 2016; 44:472-6. [DOI: 10.1002/dc.23467] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Revised: 01/30/2016] [Accepted: 02/22/2016] [Indexed: 11/06/2022]
Affiliation(s)
- Rajesh Kumar
- Department of Cytology; Postgraduate Institute of Medical Education and Research; Chandigarh India
| | - Pranab Dey
- Department of Cytology; Postgraduate Institute of Medical Education and Research; Chandigarh India
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Altinmakas E, Guo M, Kundu UR, Habra MA, Ng C. Computed tomography and 18F-fluorodeoxyglucose positron emission tomography/computed tomography findings in adrenal candidiasis and histoplasmosis: two cases. Clin Imaging 2015; 39:1115-8. [DOI: 10.1016/j.clinimag.2015.07.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Revised: 06/19/2015] [Accepted: 07/06/2015] [Indexed: 12/16/2022]
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Turashvili G, Cunningham KS. Bilateral adrenal histoplasmosis in a man with chronic alcoholism. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2015; 49:797-798. [PMID: 25908247 DOI: 10.1016/j.jmii.2015.02.660] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 02/08/2015] [Accepted: 02/10/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Gulisa Turashvili
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
| | - Kristopher S Cunningham
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada; Ontario Forensic Pathology Service, Provincial Forensic Pathology Unit, Toronto, ON, Canada.
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Lattin GE, Sturgill ED, Tujo CA, Marko J, Sanchez-Maldonado KW, Craig WD, Lack EE. From the radiologic pathology archives: Adrenal tumors and tumor-like conditions in the adult: radiologic-pathologic correlation. Radiographics 2015; 34:805-29. [PMID: 24819798 DOI: 10.1148/rg.343130127] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Advanced imaging often reveals adrenal tumors and tumor-like conditions in both symptomatic and asymptomatic patients. When adrenal disease is clinically suspected, cross-sectional imaging can be helpful in evaluating the etiology of the patient's symptoms. When adrenal disease is incidentally identified, what the clinician and patient really want to know is whether the findings are benign or malignant, as this ultimately will affect their next step in management. Using radiologic-pathologic correlation, we broadly classify common, uncommon, and rare tumors and tumor-like conditions that can occur in the adrenal as benign or malignant. This classification follows predominant trends in observed biologic behavior while acknowledging those tumors that may behave in the minority in an unpredictable manner. We review the clinical background and presentation of functional adrenal tumors including Conn syndrome, Cushing syndrome, and catecholamine-secreting tumors, as well as their relationship with adrenal anatomy. We discuss a variety of benign tumors, including adrenal cortical adenoma (including oncocytoma) and pheochromocytoma, as well as uncommonly and rarely encountered tumors such as myelolipoma, hemangioma, lymphangioma, schwannoma, ganglioneuroma, and adenomatoid tumor. A variety of tumefactive but nonneoplastic lesions are addressed, including adrenal cortical hyperplasia, adrenal hemorrhage, adrenal cysts, and infections. Malignant tumors discussed include adrenal cortical carcinoma, the rare malignant pheochromocytoma, lymphoma, metastases, and sarcomas. For each tumor and tumor-like lesion, the clinical presentation, epidemiology, key imaging findings, diagnostic differential considerations, and management options are briefly addressed. Finally, an approach to the workup of suspected or incidentally discovered tumors is presented based on a selected literature survey and our clinical experience. Radiologists play an important role in identification and diagnosis of adrenal tumors and tumor-like conditions in both symptomatic and asymptomatic patients.
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Affiliation(s)
- Grant E Lattin
- From the Department of Radiology and Radiological Sciences, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD 20814 (G.E.L., C.A.T., J.M., W.D.C.); American Institute for Radiologic Pathology, Silver Spring, Md (G.E.L., E.D.S., W.D.C.); Department of Radiology, Naval Medical Center Portsmouth, Portsmouth, Va (E.D.S.); Department of Radiology, David Grant USAF Medical Center, Travis AFB, Calif (C.A.T.); Department of Radiology, Walter Reed National Military Medical Center, Bethesda, Md (J.M.); School of Medicine, Georgetown University, Washington, DC (K.W.S.); Department of Radiology, Suburban Hospital, Bethesda, Md (W.D.C.); and Department of Endocrine Pathology, The Joint Pathology Center, Silver Spring, Md (E.E.L.)
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18F-FDG PET as a monitoring tool to assess treatment response in bilateral adrenal histoplasmosis. Clin Nucl Med 2014; 39:576-8. [PMID: 24662660 DOI: 10.1097/rlu.0000000000000400] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A 60-year-old woman with clinical and biochemical features suggestive of adrenal insufficiency was found to have bilateral adrenal masses on CT scan and was subjected to F-FDG PET scan. The scan showed hypermetabolic mediastinal nodes in addition to intense tracer uptake in bilateral adrenal masses. CT-guided adrenal biopsy grew Histoplasma capsulatum on Sabouraud dextrose agar culture. A second F-FDG PET scan after 6 months of appropriate antifungal therapy showed a significant decrease in intensity of uptake consistent with the clinical outcome.
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Abstract
The surgical treatment of adrenal tumours has evolved over the past century, as has our understanding of which hormones are secreted by the adrenal glands and what these hormones do. This article reviews the preoperative evaluation of patients with adrenal tumours that could be benign or malignant, including metastases. The biochemical evaluation of excess levels of hormones is discussed, as are imaging characteristics that differentiate benign tumours from malignant tumours. The options for surgical management are outlined, including the advantages and disadvantages of various open and laparoscopic approaches. The surgical management of adrenocortical carcinoma is specifically reviewed, including controversies in operative approaches as well as surgical management of invasive or recurrent disease.
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Affiliation(s)
- Barbra S Miller
- University of Michigan Health System, 1500 East Medical Center Drive, 2920F Taubman Center, Ann Arbor, MI 48109-5331, USA
| | - Gerard M Doherty
- Department of Surgery, Boston University, 75 East Newton Street, Boston, MA 02118, USA
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Kathuria S, Capoor MR, Yadav S, Singh A, Ramesh V. Disseminated histoplasmosis in an apparently immunocompetent individual from north India: a case report and review. Med Mycol 2013; 51:774-8. [DOI: 10.3109/13693786.2013.777166] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Adrenal hypofunction from histoplasmosis: a literature review from 1971 to 2012. Infection 2013; 41:757-9. [PMID: 23771479 DOI: 10.1007/s15010-013-0486-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Accepted: 05/25/2013] [Indexed: 12/15/2022]
Abstract
PURPOSE While histoplasmosis has been reported from most continents, the disease is most often recognized in the midwestern United States. The recent diagnosis of adrenal hypofunction in two patients with progressive disseminated histoplasmosis (PDH) in our hospital led us to review the literature. METHODS We reviewed PubMed using the search term "adrenal histoplasmosis" for the years 1971 to 2012. RESULTS The results included 242 patients with adrenal histoplasmosis from either case reports or case series. Most of the reported patients were from countries not previously considered to be heavily endemic for histoplasmosis. In addition, 41.3 % of patients with adrenal involvement developed adrenal hypofunction. CONCLUSION As modern technology elucidates more cases of adrenal histoplasmosis, the global boundaries of endemicity are being redefined.
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Wilhelm L, Martins N, Loreto ES. Histoplasmosis associated with Addison's disease. Rev Soc Bras Med Trop 2013; 46:123. [PMID: 23563844 DOI: 10.1590/0037-8682201200722013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 01/14/2013] [Indexed: 11/22/2022] Open
Affiliation(s)
- Lísea Wilhelm
- Programa de Pós-Graduação em Laboratório Clínico, Departamento de Ciências da Saúde, Universidade Regional Integrada do Alto Uruguai e dasMissões, Santo Ângelo, RS, Brasil
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Ahuja A, Mathur SR, Iyer VK, Sharma SK, Kumar N, Agarwal S. Histoplasmosis presenting as bilateral adrenal masses: cytomorphological diagnosis of three cases. Diagn Cytopathol 2012; 40:729-31. [PMID: 21387575 DOI: 10.1002/dc.21660] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Histoplasmosis is a worldwide infectious disease caused by inhalation of spores of a fungus, called Histoplasma capsulatum.Adrenals can be involved as a part of disseminated infection in immunocompromized patients. However, histoplasmosis presenting primarily as a bilateral adrenal masses in an immunocompetent patient is very unusual and rare. We encountered three such cases in which fine-needle aspiration (FNA) performed under ultrasonographic (USG) guidance from bilateral adrenal masses primarily established the diagnosis. This report emphasizes the importance of considering localized fungal infection as differential diagnoses of mass lesions involving bilateral adrenals even if the patients are immunocompetent, along with the commoner lesions at these sites.
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Affiliation(s)
- Arvind Ahuja
- Department of Pathology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
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Vyas S, Kalra N, Das PJ, Lal A, Radhika S, Bhansali A, Khandelwal N. Adrenal histoplasmosis: An unusual cause of adrenomegaly. Indian J Nephrol 2011; 21:283-5. [PMID: 22022092 PMCID: PMC3193675 DOI: 10.4103/0971-4065.78071] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Histoplasmosis is a geographically restricted form of fungal infection. Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease. Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency. We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT, and was diagnosed to have histoplasmosis on fine-needle aspiration cytology.
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Affiliation(s)
- S Vyas
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Rana C, Krishnani N, Kumari N. Bilateral adrenal histoplasmosis in immunocompetent patients. Diagn Cytopathol 2011; 39:294-6. [PMID: 20607678 DOI: 10.1002/dc.21416] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Histoplasmosis is a fungal infection caused by Histoplasma capsulatum, which commonly presents as transient pulmonary infection that usually subsides without treatment. Disseminated histoplasmosis may affect almost all systems, including the reticuloendothelial system, lungs, gastrointestinal tract, renal tract, central nervous system, bone marrow, and adrenal glands. Adrenal gland is frequently involved in disseminated histoplasmosis but commonly present as unilateral mass; bilateral involvement is rare. It is also rare in immunocompetent hosts and only few cases have been reported in past. We report four cases of adrenal histoplasmosis with bilateral involvement. These cases were initially diagnosed cytopathologically on fine needle aspirations performed on adrenal glands. All these patients were immunocompetent and two of them also had associated adrenal insufficiency. Diagnosis of adrenal histoplasmosis can be easily made on fine needle aspiration cytology. Adrenal histoplasmosis can occur in immunocompetent individuals and should be considered in differential diagnosis of bilateral adrenal masses in immunocompetent individuals.
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Affiliation(s)
- Chanchal Rana
- Department of Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, India.
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Rana C, Kumari N, Krishnani N. Adrenal histoplasmosis: a diagnosis on fine needle aspiration cytology. Diagn Cytopathol 2010; 39:438-42. [PMID: 20949473 DOI: 10.1002/dc.21453] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2010] [Accepted: 04/25/2010] [Indexed: 11/06/2022]
Abstract
Histoplasmosis is a fungal disease endemic in central and eastern states of United States, South America, Africa, and Asia. It may present as chronic pulmonary infection or in disseminated form of infection. The disseminated form of histoplasmosis frequently affects the adrenal gland and is more likely to affect immunocompromised patients as compared to immunocompetent individuals. There are very few cases of adrenal histoplasmosis diagnosed on fine needle aspiration cytology. In the present era when fine needle aspiration has become popular modality for diagnosis, adrenal fine needle aspiration is still a less commonly practiced technique. We report eight cases of adrenal histoplasmosis diagnosed on fine needle aspiration cytology in patients with bilateral adrenal masses. The present case series supports the role of fine needle aspiration cytology of adrenal gland infections where surgery can be prevented and a definitive diagnosis can be made on which treatment can be offered.
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Affiliation(s)
- Chanchal Rana
- Department of Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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Jaiswal S, Vij M, Chand G, Misra R, Pandey R. Diagnosis of adrenal histoplasmosis by fine needle aspiration cytology: an analysis based on five cases. Cytopathology 2010; 22:323-8. [PMID: 20825451 DOI: 10.1111/j.1365-2303.2010.00803.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Troh E, Doukoure B, Diomande M, Kouacou-Lohoues M, N’Dah K, Abouna A. Histoplasmose surrénalienne chez un sujet immunocompétent. À propos d’une observation à Abidjan en Côte d’Ivoire. J Mycol Med 2010. [DOI: 10.1016/j.mycmed.2010.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Rappo U, Beitler J, Faulhaber J, Firoz B, Henning J, Thomas K, Maslow M, Goldfarb D, Horowitz H. Expanding the horizons of histoplasmosis: disseminated histoplasmosis in a renal transplant patient after a trip to Bangladesh. Transpl Infect Dis 2010; 12:155-60. [DOI: 10.1111/j.1399-3062.2009.00466.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Johnson PT, Horton KM, Fishman EK. Adrenal Imaging with MDCT: Nonneoplastic Disease. AJR Am J Roentgenol 2009; 193:1128-1135. [DOI: 10.2214/ajr.09.2551] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Pamela T. Johnson
- All authors: The Russell H. Morgan Department of Radiology and Radiologic Science, Johns Hopkins School of Medicine, 601 N Caroline St., Rm. 3140D, Baltimore, MD 21287
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Shah SA, Rangarajan V, Purandare NC, Arora AJ, Sharma AR, Viswanathan S. [18F]Fluorodeoxyglucose-Avid Adrenal Masses Due to Histoplasmosis. J Clin Oncol 2009; 27:827-8. [DOI: 10.1200/jco.2008.19.9786] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Sneha A. Shah
- Bio-imaging Unit, Tata Memorial Hospital, Mumbai, India
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Abstract
BACKGROUND Findings of adrenal tuberculosis with MR scanning have never been reported in the literature. The aim of this study was to determine MR characteristics for tuberculous Addison's disease, and evaluate the utility of MR imaging as a useful diagnosis tool of the entity. PATIENTS AND METHODS Eighteen patients with proven adrenal tuberculosis were included. All patients had conventional T(1)- and T(2)-weighted image. Among the 18 patients, contrast-enhanced T(1)WI had been done in 10. MR manifestations were retrospectively evaluated blindly for the location, contour, signal intensity, and enhancement patterns. RESULTS All patients clinically exhibited hyperpigmentation and lethargy. Physical examination revealed weight loss, signs of dehydration, and hypotension. Biochemical investigation confirmed adrenal insufficiency. The adrenal glands were affected bilaterally in 16 patients (89%) and unilaterally in 2 patients (11%). Thirty-three glands were enlarged (97%), while one was atrophic (3%). Of the 33 enlarged glands, 20 (61%) were mass-like and 13 (39%) had preserved contours. The central region of the enlarged glands demonstrated T(2) hypo- or iso-SI in 21 (62%) and T(2) hyper-SI in 12 (38%). Among the 18 enlarged glands that had contrast MR, 15 (83%) had peripheral rim enhancement, 1 (6%) had homogeneous enhancement, and the last two (11%) had heterogeneous enhancement. CONCLUSION MR characteristics can reveal certain pathological changes of adrenal tuberculosis, and MR imaging could be recommended as the imaging modality for the diagnosis of the entity.
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Narang V, Sinha T, Sandhu AS, Karan SC, Srivastava A, Sethi GS, Talwar R, Prusty P, Kotwal N, Adlakha N, Aggarwal A. Clinically Inapparent Bilateral Adrenal Masses Due to Histoplasmosis. Eur Urol 2009; 55:518-21. [DOI: 10.1016/j.eururo.2008.09.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2008] [Accepted: 09/08/2008] [Indexed: 10/21/2022]
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Bahrami A, Truong LD, Shen SS, Krishnan B. Synchronous renal and adrenal masses: an analysis of 80 cases. Ann Diagn Pathol 2009; 13:9-15. [DOI: 10.1016/j.anndiagpath.2008.07.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Ma ES, Yang ZG, Li Y, Guo YK, Deng YP, Zhang XC. Tuberculous Addison's disease: morphological and quantitative evaluation with multidetector-row CT. Eur J Radiol 2007; 62:352-8. [PMID: 17466476 DOI: 10.1016/j.ejrad.2006.12.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2006] [Revised: 12/27/2006] [Accepted: 12/30/2006] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To determine the characteristics of tuberculous Addison's disease on the axial and multiplanar reformatted (MPR) images of the multidetector-row computed tomography (MDCT). MATERIALS AND METHODS The unenhanced and contrast-enhanced MDCT features in 19 patients with tuberculous Addison's disease were retrospectively assessed for the location, contour, size, calcification, attenuation, and enhancement patterns. The correlation between the duration of Addison's disease and the percentage of calcification presence was evaluated. RESULTS The adrenal glands were infected bilaterally in all of the 19 cases (100%, 38 glands). Enlargement of the glands appeared in 18 cases (94.7%, 36 glands) and the remaining one case (5.3%, two glands) showed atrophy bilaterally. Of the 36 enlarged adrenals, 13 (36.1%) had preserved contours, and the other 23 (63.9%) were mass-like. The size of the adrenals ranged from 0.6 to 4.8 cm (mean 1.92+/-0.96 cm). Calcification was revealed in 16 adrenals (16/38, 42.1%), increasing in incidence with disease progression. Fourteen of the 36 (38.9%) enlarged adrenals showed peripheral enhancement while the remaining 22 (61.1%) demonstrated heterogeneous enhancement. The DeltaCT value, the attenuation measurement of mass-like lesions, was less in the central area (7+/-4 HU) than that in the peripheral area (32+/-14 HU) (P<0.01) between the unenhanced and contrast-enhanced scan. CONCLUSION MDCT can reveal the characteristic morphology and CT attenuation in the tuberculous Addison's disease. Combined with its clinical presentations and biochemical findings, we can diagnose and stage adrenal tuberculosis with high specificity and accuracy on MDCT.
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Affiliation(s)
- En-Sen Ma
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
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Benevides CFL, Durães RO, Aquino B, Schiavon LDL, Narciso-Schiavon JL, Buzzoleti FDC. Bilateral adrenal histoplasmosis in an immunocompetent man. Rev Soc Bras Med Trop 2007; 40:230-3. [PMID: 17568895 DOI: 10.1590/s0037-86822007000200017] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2006] [Accepted: 01/17/2007] [Indexed: 11/22/2022] Open
Abstract
Histoplasmosis is a fungal disease that is endemic in Brazil. It may present as chronic pulmonary infection or in disseminated form. Disseminated histoplasmosis frequently affects the adrenal gland; however, unilateral involvement in immunosuppressed patients is the usual presentation. We report a case of an elderly immunocompetent male with history of weight loss, fever and bilateral adrenal mass who was successfully treated with itraconazole.
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Guo YK, Yang ZG, Li Y, Ma ES, Deng YP, Min PQ, Yin LL, Hu J, Zhang XC, Chen TW. Addison's disease due to adrenal tuberculosis: contrast-enhanced CT features and clinical duration correlation. Eur J Radiol 2006; 62:126-31. [PMID: 17182208 DOI: 10.1016/j.ejrad.2006.11.025] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2006] [Revised: 11/14/2006] [Accepted: 11/16/2006] [Indexed: 02/08/2023]
Abstract
PURPOSE To describe CT morphology of untreated adrenal tuberculosis during the different stages of the natural history of the disease and to evaluate the diagnostic implications of CT features. MATERIALS AND METHODS We retrospectively evaluated CT features in 42 patients with documented adrenal tuberculosis for the location, size, morphology, and enhancement patterns shown on CT images. The clinical duration were correlated with the CT features. RESULTS Of the 42 patients with untreated adrenal tuberculosis, bilaterally enlarged adrenal glands were revealed in 38 cases (91%), unilaterally enlarged in 3 cases (7%), and normal size in 1 case (2%). Of the 41 cases (98%) with enlargement, mass-like enlargement was seen in 20 cases (49%) and enlargement with preserved contours in 21 cases (51%). Peripheral rim enhancement presented in 22 cases (52%) on contrast-enhanced CT. Non-enhanced CT scan revealed calcification in 21 cases (50%). As the duration of Addison's disease increased, the presence of calcification and contour preservation increased concomitantly (p<0.001), whereas peripheral rim enhancement and mass-like enlargement decreased concomitantly on CT images (p<0.001). CONCLUSION CT may be helpful in diagnosing adrenal tuberculosis when clinically suspected, and CT features are correlated to the clinical duration of Addison's disease.
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Affiliation(s)
- Ying-Kun Guo
- Department of Radiology, West China Hospital, Sichuan University, #37 Guo Xue Xiang, Chengdu, Sichuan 610041, China
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Abstract
Diagnosis of incidental adrenal masses is a real challenge to radiologists. The most common incidental tumors of the adrenal gland are adenomas and metastases. This article presents our experience with uncommon adrenal incidentalomas. Most of the magnetic resonance imaging characteristic features are demonstrated. When possible, they are correlated with the findings at gross and microscopic analysis, to help in understanding the mechanisms by which magnetic resonance imaging may aid in the characterization of the incidental adrenal mass.
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Affiliation(s)
- Christine Hoeffel
- Université Paris - Descartes Faculté Cochin-Port-Royal, Paris, France.
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Paolo WF, Nosanchuk JD. Adrenal infections. Int J Infect Dis 2006; 10:343-53. [PMID: 16483815 PMCID: PMC7110804 DOI: 10.1016/j.ijid.2005.08.001] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2005] [Revised: 08/01/2005] [Accepted: 08/08/2005] [Indexed: 11/18/2022] Open
Abstract
Adrenal infections are an important but under-recognized clinical entity. The adrenal gland can be infected by a myriad of pathogens including fungi, viruses, parasites, and bacteria. Infection can directly or indirectly cause tissue damage and alteration in endocrine function. Direct damage occurs via microbial replication and local production of toxic compounds, such as endotoxins. Indirect damage results from alterations in the regulation of a host's immunologic and endocrine mediators in response to damage by a microbe at a distant site. Variations in pathogen tropism, adrenal anatomy, and host immune integrity contribute to the progression of active disease and discernable adrenal dysfunction. Early recognition and intervention in the case of adrenal infection can significantly improve outcome, demonstrating the need for increased clinical suspicion in the appropriate clinical setting.
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Affiliation(s)
- Jagat J Mukherjee
- Department of Medicine, National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074.
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Yildiz O, Gokce C, Alp E, Durak AC, Aygen B, Kelestimur F, Doganay M. Investigation of the hypothalamo-pituitary-adrenal axis and changes in the size of adrenal glands in acute brucellosis. Endocr J 2005; 52:183-8. [PMID: 15863945 DOI: 10.1507/endocrj.52.183] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The aim of the study was to investigate the hypothalamo-pituitary-adrenal (HPA) axis by ACTH stimulation test and the changes in adrenal size in acute brucellosis before and after therapy in a prospective study. Sixteen patients with acute brucellosis and 15 healthy subjects were included in the study during the last two years. Cortisol levels were assessed before, 30 and 60 minutes after ACTH (250 microg i.v.) injection and the size of the adrenals was measured in both groups. Mean basal cortisol levels in the patients before the therapy and after the therapy were 22.1 +/- 6.9 microg/dL and 11.3 +/- 6.0 microg/dL, respectively. The difference was statistically significant (p<0.001). There was also statistically significant difference for basal cortisol levels between the healthy subjects (12.2 +/- 4.6 microg/dL) and the patients before the therapy (p<0.001). Peak cortisol responses to ACTH were higher before the therapy in the patients with acute brucellosis (39.3 +/- 10.7 microg/dL) than in the healthy subjects (30.4 +/- 4.8 microg/dL, p = 0.014). However, there was no significant difference for peak cortisol levels in the patients before and after the therapy (32.7 +/- 8.0 microg/dL). Mean basal cortisol levels and peak cortisol responses to ACTH between the patients after the therapy and the healthy controls were similar. Both the maximum width of the adrenal glands and the width of the adrenal limbs were significantly greater before the therapy compared to healthy subjects and post-treatment period. We concluded that the HPA axis is activated and the adrenal glands are enlarged in acute brucellosis, which is reduced after appropriate therapy.
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Affiliation(s)
- Orhan Yildiz
- Department of Infectious Diseases, Faculty of Medicine, Erciyes University, Kayseri/Turkey
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Umeoka S, Koyama T, Saga T, Higashi T, Ito N, Kamoto T, Kotani H, Ogawa O, Togashi K. High 18F-fluorodeoxyglocose uptake in adrenal histoplasmosis; a case report. Eur Radiol 2005; 15:2483-6. [PMID: 15711835 DOI: 10.1007/s00330-005-2683-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2004] [Revised: 12/28/2004] [Accepted: 01/13/2005] [Indexed: 11/30/2022]
Abstract
Adrenal histoplasmosis is one of the most common adrenal granulomatous infections in endemic areas. Although CT or MRI findings of adrenal histoplasmosis have been documented, there are no reports regarding 18F-fluorodeoxyglocose (FDG) positron emission tomography (PET) findings. We report a case of bilateral adrenal histoplasmosis showing a significantly high uptake of 18F-fluorodeoxyglocose on PET study. Adrenal histoplasmosis should be considered as one of the differential diagnoses in cases of adrenal tumors with intense FDG uptake, even in non-endemic areas.
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Affiliation(s)
- Shigeaki Umeoka
- Department of Nuclear Medicine and Diagnostic Imaging, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo, Kyoto, 606-8507, Japan.
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Ikoma A, Namai K, Saito T, Kawano T, Saito T, Kasono K, Tamemoto H, Yamada S, Kawakami M, Ishikawa SE. Unilateral active adrenal tuberculosis featuring persistent intermittent fever. Endocr J 2004; 51:463-6. [PMID: 15516779 DOI: 10.1507/endocrj.51.463] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The adrenal gland is one of the organs which tuberculosis infects. In most clinical settings bilateral adrenal tuberculosis has been clarified after adrenal insufficiency is overt. On the contrary, active adrenal tuberculosis is rarely detected during the survey of infectious disease. A 68-year-old man was admitted because of intermittent fever. The fever had continued for the last 3 months. The intermittent fever was accompanied with leukocytosis and elevation of C-reactive protein. Serum soluble interleukin-2 receptor was 1920 U/ml, and beta2-microglobulin was 4.0 mg/l. Bacterial cultures of blood, sputa, urine, bone marrow and cerebrospinal fluid did not show any particular bacteria. Mycobacterium tuberculosis was negative in culture of sputa, and there was no tuberculin reaction. Plasma ACTH and serum cortisol were 18.5 pmol/l and 527.0 nmol/l, respectively. Abdominal CT scan showed right adrenal mass with a size of 28 x 20 mm, which was low density and had a well-encapsulated homogenous appearance. After the adrenalectomy, histology verified active adrenal tuberculosis. The intermittent fever disappeared, and white blood cells and C-reactive protein normalized. These findings indicate an atypical, rare case of unilateral, active adrenal tuberculosis closely linked to intermittent fever, and without any other organ involvement.
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Affiliation(s)
- Aki Ikoma
- Department of Medicine, Jichi Medical School Omiya Medical Center, Saitama, Japan
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