Bilateral adrenal histoplasmosis in an immunocompetent man

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.

"Polka Dot Macrophages" on cytology of bilateral adrenal masses-Nailing disseminated histoplasmosis

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.

Bilateral adrenal histoplasmosis in an immunocompetent man from Texas

Disseminated histoplasmosis affecting the adrenal gland(s) of immunocompetent adults is a very rare infection. Here, we present a case of bilateral adrenal histoplasmosis in an immunocompetent, 62-year-old gentleman from Texas along with a brief review of the published literature. Given the risk of patient decompensation secondary to adrenal insufficiency and the wide availability of effective treatments, adrenal histoplasmosis must be considered even in immunocompetent adults who acquire adrenal masses.

DISSEMINATED FUNGAL INFECTION WITH ADRENAL INVOLVEMENT: REPORT OF TWO HIV NEGATIVE BRAZILIAN PATIENTS

Paracoccidioidomycosis and histoplasmosis are systemic fungal infections endemic in Brazil. Disseminated clinical forms are uncommon in immunocompetent individuals. We describe two HIV-negative patients with disseminated fungal infections, paracoccidioidomycosis and histoplasmosis, who were diagnosed by biopsies of suprarenal lesions. Both were treated for a prolonged period with oral antifungal agents, and both showed favorable outcomes.

Bilateral adrenal histoplasmosis in immunocompetent patients

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.

Adrenal histoplasmosis: a diagnosis on fine needle aspiration cytology

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.