BILATERAL ADRENAL HISTOPLASMOSIS IN AN IMMUNOCOMPETENT ELDERLY PATIENT

A CASE REPORT

Abstract

INTRODUCTION
Histoplasmosis is a fungal infection caused by Histoplasma capsulatum, often acquired through inhalation of spores. Disseminated histoplasmosis with adrenal gland involvement is rare and may lead to adrenal insufficiency.

CASE
We report a case of a 70-year-old male, previously healthy, who presented with constitutional symptoms—generalized lethargy, reduced appetite, and significant weight loss of 10 kilograms within 3 months. He was normotensive and no hyperpigmentation was noted. Tumor markers and viral screening were negative and HbA1c was 6.8%. There was no hyponatremia or hyperkalemia. Morning cortisol was 341 nmol/L.

Computed tomography (CT) scan of the thorax, abdomen, and pelvis revealed bilateral mixed solid cystic adrenal masses and a wedge-shaped hypodense area in the spleen. Adrenal protocol CT showed bilateral adrenal masses measuring 5.3 x 3.7 x 3.8 cm on the right and 3.4 x 2.8 x 2.6 cm on the left. A CT-guided adrenal biopsy was performed and histopathological examination revealed highly fragmented tissue strips with large areas of necrosis and hemorrhage composed of vague formation of epithelioid granuloma with numerous fungal spores. The fungi appearing intra-cytoplasmic in H&E staining suggested histoplasmosis. Synacthen test confirmed adrenal insufficiency with a peak cortisol level of 453 nmol/L.

Intravenous amphotericin-B was administered for two weeks, followed by oral itraconazole 200 mg twice daily, alongside corticosteroid replacement for adrenal insufficiency. After 6 months, his condition improved significantly, and his adrenal size decreased on follow-up imaging (largest diameter: 3.8 cm). Itraconazole treatment was planned for a total duration of 12 months.

CONCLUSION
Bilateral adrenal histoplasmosis usually affects immunocompromised patients or those from endemic areas. This diagnosis should be considered in patients presenting with bilateral adrenal masses. Diagnosis is often delayed due to nonspecific symptoms. Imaging, serology, and biopsy are essential. Prompt antifungal treatment is imperative to prevent adrenal crises.