PRIMARY ADRENAL INSUFFICIENCY SECONDARY TO ADRENAL TUBERCULOSIS IN A KLINEFELTER SYNDROME PATIENT

DIAGNOSTIC CONUNDRUM

Abstract

CASE
Primary adrenal insufficiency (PAI) due to adrenal tuberculosis is rare. The presence of confounding factors, and comorbidities, coupled with negative culture and tissue biopsy, make the diagnosis difficult. A 56-yearold Malay male with underlying Klinefelter syndrome and diabetes presented with symptoms of adrenal crisis. Clinical examination revealed skin hyperpigmentation and hypotension. Morning cortisol was low, and ACTH washigh, suggesting PAI. Contrast-enhanced computerized tomography (CECT) scan showed bulky bilateral adrenal glands with calcification, lung granuloma, and tree-in-budappearance. Endoscopic ultrasound (EUS) guided biopsy of the left adrenal gland revealed necrotic tissue without any evidence of malignancy. Tuberculosis workouts, tumormarkers, viral screenings, and 21-hydroxylase antibodies were all negative. Following multidisciplinary discussion,empirical treatment with anti-tuberculosis therapy with steroid replacement was initiated. In conclusion, adrenal tuberculosis and Klinefelter syndrome are potential causes of PAI, and this case highlights the importance ofconsidering patients’ epidemiological background and overall clinical picture to establish diagnosis.