Answer : CT scan showed bilateral adrenal enlargement, with peripheral marginal
enhancement and central hypodense areas. Left sided adrenal gland shows peripheral
calcification.
Diagnosis :
Bilateral adrenal tuberculosis
Discussion :
Lab parameters in this patient had revealed an ESR of 48 mm at one hour (Westergren
method), a serum sodium of 128 mEq/L, and potassium of 5.5 mEq/L. Chest radiograph
revealed left apical fibrocavitatory lesion. Further biochemical investigations revealed a
low serum cortisol level and a high ACTH level confirming the diagnosis of Addison's
disease secondary to tuberculous infection.
Adrenal tuberculosis was described in 1855 by Addison; Addison's disease is characterised
by acute or chronic adrenal insufficency. Adrenal tuberculosis accounts for 30% of the
cases of Addison's disease but is often asymptomatic and is discovered at autopsy (1).
The most common radiological and CT appearance of adrenal tuberculosis is calcification
which can be diffuse, localized or punctate. CT demonstrates hypodense necrotic areas with
peripheral ring enhancement on contrast administration (2). Although adrenal calcification
is strongly suggestive of tuberculosis, it may also occur following hemorrhage, carcinoma,
neuroblastoma, cysts, and rarely in pheochromocytoma, hemangioma, or myelolipoma, and
often CT guided FNAC may be required for confirmation (3). |
References :
(1) Edlin GP. Active tuberculosis unrecognized until necropsy. Lancet 1978; 25:650-2.
(2) Lakhkar BN, Lakhkar BB, Shetty DS. Imaging in adrenal tuberculosis. Indian Pediatr
1993; 30 (2) : 1456-8.
(3) Wilms GE, Baert AL, Klint EJ, Pringot JH, Goddeeri PG. Computed tomographic findings
in bilateral adrenal tuberculosis. Radiology 1983; 146: 729-30. |
