Case 2:

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A 40 year old female presented with chief complaints of anorexia, fatigue and weight loss. Clinical examination revealed hyperpigmentation, and weight loss (7 kg in 3 months). Besides routine lab parameters, a CT scan abdomen was requested.

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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.

Contribution :Dr Rahul Sachdev, BR Diagnostics, GK1, New Delhi.