7180 Adrenal Histoplasmosis And Tuberculosis: Clinical Presentations And Prevalence Of Adrenal Insufficiency
Authors: Vorasayun Thanyaporn , Pengkhum Pornrumpa , Porntharukchareon Thachanun , Plongla Rongpong , Sasiprang Kongboonwijit , Snabboon Thiti , Warachit Parksook Wasita , Wannachalee Taweesak , Sunthornyothin Sarat 
Published: October 2024

Disclosure: T. Vorasayun: None. P. Pengkhum: None. T. Porntharukchareon: None. R. Plongla: None. K. Sasiprang: None. T. Snabboon: None. W.W. Parksook: None. T. Wannachalee: None. S. Sunthornyothin: None.

Background: Adrenal infection is an important cause of adrenal insufficiency (AI). Commonly reported pathogens are Histoplasma capsulatum and Mycobacterium tuberculosis (TB). These two pathogens can cause similar clinical presentations, yet patients require different specific treatments. Methods: We performed a retrospective study of patients with adrenal histoplasmosis and TB at two referral centers in Bangkok, Thailand. Adrenal infection was diagnosed by proven microbiologic evidence of infection and morphologic adrenal abnormalities on cross-sectional imaging. We evaluated clinical characteristics, prevalence of AI, and treatment. Results: Of the 47 patients, 33 (70%) had adrenal histoplasmosis, 13 (28%) had adrenal TB, and 1 (2%) had coinfection with both pathogens. The majority were HIV-negative (91%) and males (whole cohort; 81%, histoplasmosis; 94%, TB; 54%, coinfection; 100%). The mean age at the diagnosis was 64 years in patients with adrenal histoplasmosis and 49 in adrenal TB. One patient with coinfection was 84 years. Extra-adrenal manifestations were 55%, 77%, and 100% in patients with adrenal histoplasmosis, TB, and coinfection, respectively. At presentation, all patients with adrenal histoplasmosis had anorexia/weight loss, while this symptom was present in 54% of patients with adrenal TB. The most common presentation in adrenal TB was hyperpigmentation (77%), while it was documented in less than half of adrenal histoplasmosis (45%). On cross-sectional imaging, the majority (83%) had bilateral adrenal abnormalities, of which 81% were mass-like. The median diameter of the adrenal lesions with histoplasmosis infection was 5.6 and 5.4 cm on the right and left adrenal glands, respectively, while the median diameter of the adrenal lesions with TB infection was 3.2 cm on both sides. The prevalence of AI was 88% in the whole cohort (83% in adrenal histoplasmosis, 100% in adrenal TB and coinfection). In patients with AI, the median 8 AM cortisol levels were 4 ug/dl (histoplasmosis; 8.0 ug/dl and TB; 2.3 ug/dl), and the median ACTH levels were 431 pg/ml (histoplasmosis; 189 pg/ml and TB; 1377 pg/ml). During a median follow-up time of 22 months, 100% received antituberculosis/antifungal agents, while only 21% underwent adrenalectomy, in which most patients were those with adrenal histoplasmosis. All patients with AI received steroid replacement, yet 11% had an adrenal crisis. There was no HPA axis recovery in any AI patients. Conclusion: There were high rates of AI in patients with adrenal histoplasmosis and/or TB. No recovery of the HPA axis was observed, even after antifungal/TB agents and without bilateral adrenalectomy. Most patients were non-HIV males and had bilateral mass-like adrenal lesions. There was a slightly higher prevalence of extra-adrenal manifestations and AI in TB, and it affected more women than histoplasmosis.

Presentation: 6/3/2024