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

Acute spontaneous non-hemorrhagic adrenal infarction with systemic lupus erythematosus and antiphospholipid antibody syndrome: A case report

RATIONALE

Adrenal infarction (AI) is a rare type of adrenal damage, which is relatively common in systemic lupus erythematosus, antiphospholipid antibody syndrome (APS) and pregnancy. The diagnosis of AI is mainly by computed tomography (CT) and magnetic resonance imaging, but is easily confused with other adrenal disease. Hence, this report details a condition of AI with systemic lupus erythematosus, APS and made a differential diagnosis from imaging.

PATIENT CONCERNS

We report a case of a 55-year-old woman with pain in her fossa axillaries and inguinal regions. Then CT scan disclosed bilateral adrenal diseases, and the patient was diagnosed with systemic lupus erythematosus, APS and AI after additional autoimmune examinations.

DIAGNOSES

The patient was diagnosed as systemic lupus erythematosus with lupus nephritis, hematological damage and oromeningitis, APS, AI and secondary blood coagulation disorders.

INTERVENTIONS

The patient was treated with methylprednisolone, hydroxychloroquine and low molecular heparin.

OUTCOMES

The patient relieves and remains well 1 year after treatment.

LESSONS SUBSECTIONS

AI can be divided hemorrhagic and non-hemorrhagic, with bilateral lesions more common. In our case, the AI was bilateral, partially involved and non-hemorrhagic, and the "cutoff sign" was first put forward in CT, which might assist the diagnosis.

A retrospective analysis of 25 cases of Addison's disease caused by adrenal tuberculosis in Tibet and review of related literature

Background

To investigate the clinical characteristics of Addison's disease caused by adrenal tuberculosis in Tibet. After the anti-tuberculosis treatment, the clinical features between continuous glucocorticoid therapy and glucocorticoid withdrawal were analyzed.

Methods

Clinical data of patients with Addison's disease caused by adrenal tuberculosis diagnosed in The People's Hospital of Tibet Autonomous Region from January 2015 to October 2021 were collected and analyzed. All patients were taking anti-tuberculosis and glucocorticoids replacement therapy, and the root cause of the disease was analyzed following prognosis observations.

Results

There were 25 patients (24 Tibetan and 1 Han patient) with Addison's disease caused by adrenal tuberculosis, including 18 males and 7 females. A total of 21 cases were followed up successfully, of which 13 cases discontinued anti-tuberculosis drugs successfully, 6 cases discontinued glucocorticoid therapy among the rest, 6 cases continued anti-tuberculosis + glucocorticoid replacement therapy, and 2 cases died.

Conclusion

Early diagnosis and proper anti-tuberculosis treatment can improve the prognosis of patients with adrenal tuberculosis. Moreover, screening and educating Tibetan people regarding the potential risk and adversities of adrenal tuberculosis is crucial for eradicating the disease.

Clinical analysis of the etiological spectrum of bilateral adrenal lesions: A large retrospective, single-center study

PURPOSE

To investigate the clinical characteristics, endocrinological function, and etiology of bilateral adrenal lesions in hospitalized patients.

METHODS

A retrospective study of 777 patients with bilateral adrenal lesions was conducted at the Chinese People's Liberation Army General Hospital between January 2013 and January 2018. Patients' demographic features, hormonal profiles, imaging findings, and histopathological findings were reviewed from database records.

RESULTS

Of the 777 patients with bilateral adrenal lesions, 495 were men. The mean age at diagnosis was 52.0 ± 13.0 years. Overall, 511 (65.8%) cases were benign, followed by adrenal metastases (n = 224, 28.8%), pheochromocytoma (n = 26, 3.3%), adrenal lymphoma (n = 9, 1.2%), and adrenal corticocarcinoma (ACC; n = 7, 0.9%). Hormonal evaluation revealed that 34.3% of bilateral adrenal lesions were functional. The primary etiologies of functional lesions were primary aldosteronism (16.6%, 129/777), and primary bilateral macronodular adrenocortical hyperplasia (PBMAH; 8.8%, 68/777). Patients with lymphoma and metastases were significantly older than those with benign nonfunctional lesions (60.4 ± 11.0 years vs. 54.5 ± 10.4 years and 57.9 ± 10.8 years vs. 54.5 ± 10.4 years, respectively; both P < 0.001). Lesions in patients with adrenal lymphoma, ACC, pheochromocytoma, metastases, congenital adrenal hyperplasia, tuberculosis, and Cushing's syndrome were significantly larger than benign nonfunctional lesions (all P < 0.001).

CONCLUSION

Benign adrenal lesions and metastases from the lungs are the most common causes of bilateral adrenal lesions. Primary aldosteronism and PBMAH are the most prevalent functional lesions. Moreover, patients with lymphoma or metastases are older and their masses are larger.

Bilateral adrenal masses due to tuberculosis: how to diagnose without extra-adrenal tuberculosis

SUMMARY

Primary adrenal insufficiency is a rare disease and can masquerade as other conditions; therefore, it is sometimes incorrectly diagnosed. Herein, we reported the case of a 39-year-old Vietnamese male with primary adrenal insufficiency due to bilateral adrenal tuberculosis. The patient presented to the emergency room with acute adrenal crisis and a 3-day history of nausea, vomiting, epigastric pain, and diarrhoea with a background of 6 months of fatigue, weight loss, and anorexia. Abdominal CT revealed bilateral adrenal masses. Biochemically, unequivocal low morning plasma cortisol (<83 nmol/L) and high plasma adrenocorticotropic hormone levels were consistent with primary adrenal insufficiency. There was no evidence of malignancy or lymphoma. As the patient was from a tuberculosis-endemic area, extra-adrenal tuberculosis was excluded during the work up. A retroperitoneal laparoscopic left adrenalectomy was performed, and tuberculous adrenalitis was confirmed by the histopathological results. The patient was started on antituberculous therapy, in addition to glucocorticoid replacement. In conclusion, even without evidence of extra-adrenal tuberculosis, a diagnosis of bilateral adrenal tuberculosis is required. A histopathological examination has a significant role along with clinical judgement and hormonal workup in establishing a definitive diagnosis of adrenal tuberculosis without evidence of active extra-adrenal involvement.

LEARNING POINTS

Primary adrenal insufficiency can be misdiagnosed as other mimicking diseases, such as gastrointestinal illness, leading to diagnostic pitfalls. Adrenal insufficiency can be confirmed with significantly low morning plasma cortisol levels of <83 nmol/L without a dynamic short cosyntropin stimulation test. Tuberculous adrenalitis is an uncommon treatable condition; however, it remains an important cause of primary adrenal insufficiency, especially in developing countries. In the absence of extra-adrenal involvement, adrenal biopsy plays a key role in the diagnostic process. Alternatively, adrenalectomy for histopathological purposes should be considered if CT scan-guided fine needle aspiration is infeasible in cases of small adrenal masses.

Adrenalitis tuberculosa: a propósito de una actualización

Introducción: la insuficiencia suprarrenal primaria (IA) descrita por Thomas Addison en 1855 atribuía como principal causa a la infección por tuberculosis (TBC) diseminada, pero con el paso del tiempo ha disminuido en los países desarrollados. En aquellos en vías de desarrollo se mantiene alta esta etiología infecciosa, en especial en pacientes con VIH. Objetivo: realizar una revisión narrativa de la literatura reciente sobre la adrenalitis TBC, incluyendo el enfoque, manejo y seguimiento en los casos de insuficiencia suprarrenal primaria (IA). Materiales y métodos:  búsqueda y análisis de los artículos disponibles en los últimos 5 años bajo los descriptores en ciencias de la salud (DeCS) enfermedad de Addison, tuberculosis, insuficiencia suprarrenal primaria y adrenalitis en español en las bases de Google scholar y LILACS, y en inglés en PubMed y ClinicalKey. Conclusiones:  la insuficiencia adrenal o adrenalitis por TBC ha descendido como causa de IA primaria, pero en el contexto de reemergencia de infección por VIH, continúa siendo una causa importante de IA en países en desarrollo. En estos casos además de la suplencia con corticosteroides el tratamiento de la causa específica es de importancia para impactar en la respuesta clínica, la supervivencia y la calidad de vida.

A pictorial review of non-traumatic adrenergic crisis

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.

Tuberculosis as a differential for bilateral adrenal masses in the UK

Primary adrenal insufficiency (PAI) is a potentially fatal disease. Adrenal tuberculosis(TB) causing PAI is rare in the developed world. We present a seemingly well, 78-year-old Caucasianwoman in the UK who developed adrenal crisis following elective hip surgery. Biochemical tests confirmed PAI and steroid replacement was initiated. Imaging of the abdomen demonstrated bilateral adrenal masses and a fluorodeoxyglucose positron emission tomography (FDG-PET) scan showed increased uptake in both adrenals suggestive of malignancy. Following a retroperitoneoscopic left adrenalectomy, histology showed caseating necrosis with xanthogranulomatous inflammation favouring a diagnosis of TB. She was commenced on anti-TB treatment. Diagnosing adrenal TB in the west can be challenging especially in the absence of extra-adrenal TB. FDG-PET scans can be falsely positive in presence of chronic active inflammatory conditions, such as TB, and a tissue diagnosis is required. It is important that clinicians remain vigilant of this important disease, which can masquerade as malignancy.

The hollow adrenal gland sign: a newly described enhancing pattern of the adrenal gland on dual-phase contrast-enhanced CT for predicting the prognosis of patients with septic shock

OBJECTIVE

To investigate the incidence, CT appearance, and implication for prognosis of the hollow adrenal gland sign (HAGS).

METHODS

A total of 194 patients with septic shock and 24 patients with hemorrhagic shock (as control group) were retrospectively included in this study and the patients with septic shock were further divided into four subgroups (digestive tract diseases, DTD, n = 49; biliary and pancreatic diseases, BPD, n = 41; postsurgical infection, PI, n = 64; and other diseases, OD, n = 40). All patients underwent a dual-phase contrast-enhanced CT within 1 week after diagnosis. CT findings and clinical records were reviewed. If in the arterial phase the central zone of adrenal gland showed temporally much lower attenuation than the peripheral zone, it was defined as HAGS positive. The incidence of the HAGS in patients with septic shock and hemorrhagic shock, the demographic features, and mortality between HAGS-positive and HAGS-negative patients in each group were respectively compared.

RESULTS

The incidence of the HAGS in the septic shock group was nearly 30%, while it was 0 in the hemorrhagic shock group. There was no significant difference in age or gender between HAGS-positive and HAGS-negative patients in all groups, while the mortality of HAGS-positive patients was significantly higher than that of HAGS-negative patients in each group (p < 0.05). The concordance correlation coefficient value showed excellent reproducibility of the two observers (κ = 0.977).

CONCLUSION

The HAGS is specific and common on dual-phase contrast-enhanced CT in patients with septic shock and predicts a poor prognosis.

KEY POINTS

• The hollow adrenal gland sign (HAGS) newly described in this study is a special enhancing pattern of adrenal gland on dual-phase contrast-enhanced CT in patients with septic shock. • The HAGS is characterized by the much lower-attenuated central zone of the adrenal gland in arterial phase and it showed excellent reproducibility between different observers. • The HAGS is specific and common on dual-phase contrast-enhanced CT in patients with septic shock and predicts a poor prognosis.

Imaging features of adrenal masses

The widespread use of imaging examinations has increased the detection of incidental adrenal lesions, which are mostly benign and non-functioning adenomas. The differentiation of a benign from a malignant adrenal mass can be crucial especially in oncology patients since it would greatly affect treatment and prognosis. In this setting, imaging plays a key role in the detection and characterization of adrenal lesions, with several imaging tools which can be employed by radiologists. A thorough knowledge of the imaging features of adrenal masses is essential to better characterize these lesions, avoiding a misinterpretation of imaging findings, which frequently overlap between benign and malignant conditions, thus helping clinicians and surgeons in the management of patients. The purpose of this paper is to provide an overview of the main imaging features of adrenal masses and tumor-like conditions recalling the strengths and weaknesses of imaging modalities commonly used in adrenal imaging.

Endocrine and Metabolic Aspects of Tuberculosis

Endocrine and metabolic derangements are infrequent in patients with tuberculosis, but they are important when they occur. The basis for these abnormalities is complex. While Mycobacterium tuberculosis has been described to infect virtually every endocrine gland, the incidence of gland involvement is low, especially in the era of effective antituberculosis therapy. Furthermore, endocrine and metabolic abnormalities do not always reflect direct infection of the gland but may result from physiological response or as a consequence of therapy. Metabolic disease may also predispose patients to the development of active tuberculosis, particularly in the case of diabetes mellitus. While hormonal therapy may be necessary in some instances, frequently these endocrine complications do not require specific interventions other than antituberculous therapy itself. With the exception of diabetes mellitus, which will be covered elsewhere, this chapter reviews the endocrinologic and metabolic issues related to tuberculosis.

Imaging in extrapulmonary tuberculosis

Tuberculosis (TB) remains a major global public health problem, with 1.5 million deaths annually worldwide. One in five cases of TB present as extrapulmonary TB (EPTB), posing major diagnostic and management challenges. Mycobacterium tuberculosis adapts to a quiescent physiological state and is notable for its complex interaction with the host, producing poorly understood disease states ranging from latent infection to active clinical disease. New tools in the diagnostic armamentarium are urgently required for the rapid diagnosis of TB and monitoring of TB treatments, and to gain new insights into pathogenesis. The typical and atypical imaging features of EPTB are reviewed herein, and the roles of several imaging modalities for the diagnosis and management of EPTB are discussed.