Tuberculous Addison's disease: morphological and quantitative evaluation with multidetector-row CT

Addison's disease triggered by infection with mycobacterium abscessus, but not by adrenal tuberculosis or MAC pulmonary disease, in a subject with type 2 diabetes mellitus: case report

BACKGROUND

Addison's disease is primary adrenal dysfunction and is characterized by decrease of cortisol level and increase of adrenocorticotropic hormone (ACTH) level. It is known that infection is one of main causes of Addison's disease. Among various infections, tuberculous infection accounts for the majority of them. Recently the number of subjects with non-tuberculous mycobacterial infection has been increased, and the infection can also bring about Addison's disease. Mycobacterium avium complex (MAC) pulmonary disease accounts for the majority of non-tuberculous mycobacterial infection.

CASE PRESENTATION

An 83-year-old female was suspected of having adrenal failure in our outpatient care and hospitalized in our institution. There was pigmentation in her face, hands and legs, especially in auricle and nail beds in her hands and legs. In rapid ACTH load test (0.25 mg of 1-24 ACTH), cortisol level was not increased at all. An abdominal computed tomography (CT) showed swelling of both adrenal glands accompanied by calcification. QuantiFERON test was negative and mycobacterium tuberculosis complex was negative in PCR test using bronchial lung lavage fluid. These data ruled out the possibility of adrenal tuberculosis. It is known that MAC pulmonary disease accounts for the majority of non-tuberculous mycobacterial infection. In this subject, however, anti-MAC antibody was negative and MAC-related bacteria were not detected in PCR test using bronchial lung lavage fluid. These data ruled out the possibility of MAC pulmonary disease. Mycobacterium abscessus (Mab) was positive in bronchial lung lavage fluid culture. Based on these data, we diagnosed this subject with Addison's disease triggered by infection with mycobacterium abscessus, but not by adrenal tuberculous or MAC pulmonary disease. Decreased sodium level and increased eosinophil number were normalized and appetite loss was markedly mitigated after starting hydrocortisone therapy. A chest CT which was taken about 6 months later showed drastic reduction of consolidation in the upper lobe of the left lung although calcification in the adrenal gland was still observed.

CONCLUSIONS

We should bear in mind the possibility of Addison's disease triggered by another type of infection rather than adrenal tuberculosis or MAC pulmonary disease.

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

BACKGROUND

Adrenal tuberculosis usually presents with bilateral involvement. It has special characteristics in computed tomography (CT) images, such as small size, low attenuation in the center, and peripheral rim enhancement, which differ from those of primary tumors.

CASE SUMMARY

A 42-year-old female presented to the hospital with low back pain. She had been diagnosed with hypertension as well as pulmonary and cerebral tuberculosis but denied having any fever, fatigue, anorexia, night sweats, cough, or weight loss. Abdominal CT revealed an irregular 6.0 cm × 4.5 cm mass with uneven density in the right adrenal gland, while the left adrenal gland was normal. No abnormalities were observed in plasma total cortisol (8 am), adrenocorticotropic hormone, aldosterone/renin ratio, blood catecholamines, or urine catecholamines. A fine-needle aspiration biopsy of the right adrenal gland provided evidence of tuberculosis. After three years of anti-tuberculosis treatments, the large mass in the right adrenal gland was reduced to a slight enlargement.

CONCLUSION

This is a case of unilateral adrenal tuberculosis with CT imaging characteristics mimicking those of a malignant tumor. Extended anti-tuberculosis therapy is recommended in such cases.

Current Approach for Diagnosis and Treatment of Adrenal Tuberculosis-Our Experience and Review of Literature

Addison's disease was first described by Thomas Addison in 1855. He demonstrated the destruction of bilateral adrenal gland by tuberculosis (TB) in six patients. Since then, the incidence of TB has declined in the Western world, but in developing countries, it is still the most common cause of adrenal insufficiency. Because of the introduction of antituberculous chemotherapy, the incidence of adrenal TB has been declined in the past decades. The most common symptoms are nonspecific; therefore, diagnosis is often delayed, and patients may first present with a life-threatening adrenal crisis. The most commonly identified organism for adrenal failure in adrenal TB is Mycobacterium tuberculosis infection. Adrenal TB involves bilateral adrenal glands more frequently than unilateral glands. Computed tomography (CT) scan and magnetic resonance imaging (MRI) are useful investigations to differentiate between tuberculous Addison's disease and the other causes of adrenal insufficiency. In CT scans or MRI, features of adrenal TB are bilateral adrenal enlargement and peripheral rim enhancement with or without calcifications. Antituberculous drugs, biochemical monitoring of adrenal function, and steroid therapy are essential for the management of adrenal TB and adrenal insufficiency. Here, we describe a case of adrenal TB with abscess formation followed by a review of the current literature of adrenal TB for better diagnosis and management of this condition.

Technical and Interpretive Pitfalls in Adrenal Imaging

The adrenal gland may exhibit a wide variety of pathologic conditions. A number of imaging techniques can be used to characterize these, although it is not always possible to attain a definitive diagnosis radiologically. Incorrect diagnoses may be made if radiologists are not attentive to technical parameters and interpretive factors associated with adrenal gland imaging. Hence, an appreciation of the intricacies of adrenal imaging strategies and characterization is required; this can be aided by understanding the pitfalls of adrenal imaging. Technical pitfalls at CT may relate to the imaging parameters, including region of interest characteristics, tube voltage selection, and the timing of contrast material-enhanced imaging. With MRI, imaging acquisition technique and evaluation of the reference tissues used in chemical shift MRI are important considerations that can directly influence image interpretation. Interpretive errors may occur when evaluating adrenal washout at CT without considering other radiologic features, including the size of adrenal nodules, the presence of fat or calcification, the attenuation of nodules, and atypical imaging features. The characterization of an incidental adrenal lesion as benign or malignant does not end the role of the radiologist; consideration as to whether an adrenal lesion is associated with endocrine dysfunction is required. While imaging may not be optimal for establishing endocrine activity, there are imaging features from which radiologists may infer function. In cases of known endocrine activity, imaging can guide clinical management, including further investigations such as venous sampling. ^©RSNA, 2020.

Results of Percutaneous Computed Tomography-Guided Biopsy of Adrenal Lesions and Spectrum of Computed Tomography Findings

Objective

Adrenal enlargement occurs in various conditions such as infections, benign, and malignant neoplasms. Percutaneous computed tomography (CT)-guided adrenal biopsy is a safe method for obtaining tissue specimen in cases where diagnosis cannot be established on imaging and biochemical grounds. The study aims to evaluate diagnostic yield, accuracy, and complications of percutaneous CT-guided adrenal biopsies. Furthermore, CT findings of various adrenal lesions have been described.

Materials and Methods

Data of CT-guided adrenal biopsies performed from September 2009 to May 2019 were analyzed. Biopsies were performed on a 64-slice or a 128-slice multidetector CT scanner using a coaxial technique. Pathological and microbiological reports were retrieved from the hospital information system. Clinical details were obtained from clinical case records.

Results

CT-guided adrenal biopsies were performed in 48 patients, 37 males and 11 females. Adrenal insufficiency was present in 31 (64%) cases and bilateral adrenal glands were affected in 35 (73%). Biopsy yielded a diagnosis in 35 cases (72.9%). The final diagnosis was achieved in 43 (90%) cases. Combined accuracy of CT-guided biopsy for identifying malignancy and infection was 88.3%. Adrenal histoplasmosis (AH) was the most common entity diagnosed (44%). After combining histopathology and microbiology results, the sensitivity for diagnosing AH was 100%. One (2%) patient had a major complication in the form of intra-abdominal hemorrhage requiring transfusion. Local hematoma and mild stable pneumothorax were noted in one patient each.

Conclusion

Percutaneous CT-guided biopsy is a safe procedure for the diagnosis of adrenal lesions. It has good accuracy for diagnosing adrenal conditions such as infections and malignancies. However, the specific diagnosis of benign adrenal lesions was difficult to make. AH, tuberculosis, and metastasis have overlapping imaging findings.

Familial Cerebral Cavernous Malformations Are Associated with Adrenal Calcifications on CT Scans: An Imaging Biomarker for a Hereditary Cerebrovascular Condition

Purpose To determine if adrenal calcifications seen at computed tomography (CT) are associated with familial cerebral cavernous malformations (fCCMs) in carriers of the CCM1 Common Hispanic Mutation. Materials and Methods This study was approved by the institutional review board. The authors retrospectively reviewed abdominal CT scans in 38 patients with fCCM, 38 unaffected age- and sex-matched control subjects, and 13 patients with sporadic, nonfamilial cerebral cavernous malformation (CCM). The size, number, and laterality of calcifications and the morphologic characteristics of the adrenal gland were recorded. Brain lesion count was recorded from brain magnetic resonance (MR) imaging in patients with fCCM. The prevalence of adrenal calcifications in patients with fCCM was compared with that in unaffected control subjects and those with sporadic CCM by using the Fisher exact test. Additional analyses were performed to determine whether age and brain lesion count were associated with adrenal findings in patients with fCCM. Results Small focal calcifications (SFCs) (≤5 mm) were seen in one or both adrenal glands in 19 of the 38 patients with fCCM (50%), compared with 0 of the 38 unaffected control subjects (P < .001) and 0 of the 13 subjects with sporadic CCM (P = .001). Adrenal calcifications in patients with fCCM were more frequently left sided, with 17 of 19 patients having more SFCs in the left adrenal gland than the right adrenal gland and 50 of the 61 observed SFCs (82%) found in the left adrenal gland. No subjects had SFCs on the right side only. In patients with fCCM, the presence of SFCs showed a positive correlation with age (P < .001) and number of brain lesions (P < .001). Conclusion Adrenal calcifications identified on CT scans are common in patients with fCCM and may be a clinically silent manifestation of disease. ^© RSNA, 2017.

Evaluation of primary adrenal insufficiency secondary to tuberculous adrenalitis with computed tomography and magnetic resonance imaging: Current status

As one kind of infectious diseases of adrenal gland, adrenal tuberculosis can result in a life-threatening disorder which is called primary adrenal insufficiency (PAI) due to the destruction of adrenal cortex. Computed tomography (CT) and magnetic resonance imaging (MRI) play significant roles in the diagnosis of this etiology of PAI based on the CT and MRI appearances of the adrenal lesions. In this mini-review, we intend to study the CT and MRI features of adrenal tuberculosis, which could be helpful to both endocrinologist and radiologist to establish a definitive diagnosis for adrenal tuberculosis resulting in PAI.

Surgical management of adrenocortical tumours

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.

Pattern of adrenal morphology and function in pulmonary tuberculosis: response to treatment with antitubercular therapy

OBJECTIVE

Although previous studies have shown enlargement of adrenal glands in patients with tuberculosis, only few have studied its natural history. Similarly, there have been variable reports of adrenal function in these patients. Some but not all the studies revealed a high prevalence of adrenal insufficiency. The aim of this study was to prospectively study the adrenal cortical function and morphology before and after treatment of pulmonary tuberculosis.

DESIGN AND PATIENTS

In a prospective case-control study, 45 patients with acute pulmonary tuberculosis and 45 healthy age- and gender-matched controls were studied. Adrenal function was tested using a short Synacthen test at the baseline and after 6 months of antitubercular treatment. Size of both adrenal glands was studied using 64 slice MDCT (Somatom Sensation, Siemens) before and after 6 months of antitubercular treatment. The findings were compared with a group of healthy controls.

RESULTS

The mean age of cases was 42·4 ± 20·4 years and that of controls was 41·1 ± 17·7 years. The various clinical and biochemical parameters were comparable between cases and controls. The mean cortisol both basal and one-hour postintravenous Synacthen was significantly lower in cases as compared to controls (mean ± SD basal cortisol of 413·57 ± 108·42 nmol/l in cases vs 615·26 ± 108·15 nmol/l in controls and post Synacthen cortisol of 685·61 ± 83·87 nmol/l in cases vs 1497·30 ± 734·44 nmol/l in controls). Both the adrenal length and thickness of the right and left adrenal gland were greater in patients with active tuberculosis compared with controls and reversed to baseline after completion of antitubercular treatment.

CONCLUSION

Adrenal enlargement demonstrated by CT is common in active tuberculosis and is reversible. Basal and stimulated cortisol is less in patients with pulmonary tuberculosis as compared with healthy controls and increases after antitubercular treatment, although unlike previous studies, none of the patients had adrenal insufficiency.