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A CASE OF TUBERCULOSIS ADRENAL INSUFFICIENCY
محمود شاكر خضير
Authors : Mustafa Mohamed Abdu Lateef and Mahmood Shakir Khudhair
\r\nClinical Case: 40-year-old man, sanitation worker, presents with 3 months history of significant weight loss and fever with night sweating. He complains of nausea, occa-sional vomiting, fatigue, unintentional weight loss of approxi-mately 12 kg, decreased appetite, abdominal pain and joint pain. He also reports skin hyperpigmentation particularly in the hand creases, mouth and mucous membranes of the lips. There are no respiratory symptoms such as shortness of breath or cough. The past medical history is unremarkable. There is positive family history of pulmonary tuberculosis (grandmother). He does not smoke or drink alcohol. Physical examination reveals ill-looking malnourished patient, with BP of 100/60 with postural hypotension, PR of 80 bpm and RR of 24/min. There is diffuse hyperpigmen-tation particularly noted in palmer creases and oral cavity. The other system examinations are normal. Laboratory investigations revealed mild normochromic normocytic anemia (Hb 11.4), and mild lymphocytosis, Na 126 mEq/l, k 4.1 mEq/l, FBS 87 mg/dl, high ESR, mild ele-vation of TSB 1.8 mg/dl normal renal function, morning cor-tisol of 0.75 Mcg/dl and morning ACTH of 1808 pg/ml. Imaging studies show a normal chest X-ray. Abdominal CT reveals bilateral adrenal enlargement in size with lobulated irregular contours and heterogeneous density exhibiting foci of calcification and central cystic/necrotic non-enhancing cen-ters, with predominantly peripheral enhancement seen on the contrast scan. The mean density of the solid parts of the glands is around 30-40 HU on the native scan, the right ad-renal measures 2.7x1.7x2.7 cm, the left adrenal measures\r\n5.6x3.2x2.5 cm. IGRA test is positive. Adrenal biopsy was not performed because the presentation was highly suggest-ive of adrenal tuberculosis.The diagnosis was primary ad-renal insufficiency due to adrenal tuberculosis Anti TB drugs were initiated on standard regimen of INH, Rifampicin, Pyrazinamide, and Ethambutol. Hydrocortisone replacement was initiated. The patient required higher dose of hydrocortisone (20 mg in the morning, 10 mg at 6 pm) which could be due to CYP 3A4 induction by rifampicin Fludrocortisone 0.1mg daily was also started. The patient\'s symptoms improve dramatically after initiation of treat-ments, with gradual increase in body \r\n\r\n

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January 2025