ADRENAL INSUFFICIENCY SECONDARY TO BILATERAL ADRENAL HISTOPLASMOSIS IN AN IMMUNOCOMPETENT ELDERLY PATIENT

Abstract

INTRODUCTION

Chronic progressive disseminated histoplasmosis commonly affects older patients who are not overtly immunocompromised and carries a high mortality risk if left untreated. Adrenal gland involvement is common in disseminated histoplasmosis but hypoadrenalism does not ensue invariably.

METHODOLOGY

We illustrate a case of an immunocompetent elderly patient who presented with adrenal insufficiency secondary to bilateral adrenal histoplasmosis four years after a diagnosis of oral mucocutaneous histoplasmosis.

RESULTS

A hypertensive, immunocompetent, 73-year-old female with a history of chronic exposure to birds was treated for oral mucocutaneous histoplasmosis in January 2017. She was lost to follow-up after all her oral lesions resolved following 12 weeks of itraconazole therapy. Four years later, she was admitted for progressively worsening lethargy and weight loss over a month, accompanied by biochemical evidence of hyponatremia, hyperkalemia as well as a random cortisol level of 259 nmol/L. Baseline adrenocorticotropic hormone (ACTH) and ACTH stimulation tests were not performed. Plain computed tomography (CT) of abdomen and pelvis showed presence of bilateral adrenal heterogeneous enlargement with specks of calcification within the adrenals. The right adrenal measured 6.1 cm × 4.5 cm × 5.7 cm and the left adrenal measured 5.7 cm × 2.9 cm × 4.4 cm. A diagnosis of adrenal insufficiency was made and oral glucocorticoid therapy was initiated. Following an episode of Addisonian crises precipitated by urinary tract infection, she was seen in the endocrine clinic in our hospital, during which an adrenal biopsy was planned. While waiting for the procedure, she was admitted for relapsed histoplasmosis with oral mucocutaneous and cervical lymph node involvements. Itraconazole therapy was subsequently reinstituted, along with hydrocortisone and fludrocortisone replacement. She succumbed to the disease three days later.

CONCLUSION

Although hypoadrenalism does not always complicate adrenal histoplasmosis, its presence should be sought particularly when both adrenal glands are involved. The prospect of adrenal function recovery ensuing antifungal therapy is still uncertain to date.