ODP048 Large Bilateral Adrenal Lesions Abutting Right Hemidiaphragm in a Man from Texas
Authors: Gosmanova Albina , Gosmanov Camil , Scofield Hal 
Published: November 2022

Abstract
Sporadic cases of disseminated histoplasmosis (DHI) have been reported in several regions of the US, mainly inimmunocompromised patients where involvement of the adrenal gland, either unilaterally or bilaterally, is often being the only demonstrable site of active fungal disease in the setting of nonspecific clinical complaints. While DHI is not immediately life-threatening, adrenal involvement might be the most concerning complications due to potential risk of the gland destruction by the expanding infection or its treatment; it is considered that adrenal insufficiency is one of the most common causes of death in patients with DHI. We present a case of 78-year-old immunocompetent gentleman with history of hypertension, ischemic heart disease, atrial fibrillation and 30 pack-years of cigarette smoking who presented with low-grade fever, anorexia and 30 lbs weight loss. As a part of diagnostic evaluation, CT abdomen was performed and bilateral adrenal lesions were reported: right adrenal mass measured 4.6×3.4 cm, and the left adrenal mass 4.1×3.2 cm in maximal axial dimensions. Of note, the right adrenal mass abutted the crus of the right hemidiaphragm and undersurface of the liver. Hormonal evaluation was performed and did not show any excess secretions. GI consult was called for evaluation of adrenal gland access and biopsy: endoscopic ultrasound guided FNA biopsy access was performed and revealed findings compatible with adrenal histoplasmosis and no malignant cells. ID consult was sought: evaluation and prompt start of antifungal therapy were undertaken: IV Amphotericin B, followed by oral Itraconazole for total of 12 months. Patient has remained stable during initial evaluation: due to his age and comorbid conditions, he was admitted to the hospital during which Cosyntropin stimulation test was performed: results have revealed 12.9 at baseline and 17.6 after stimulation. Interdisciplinary discussion was held and resulted in decision to start steroid replacement therapy due to rather mild response to stimulation and significant risk of collateral damage to the remaining adrenal tissue during the antifungal therapy. Patient has responded to therapy well, though had some worsening of his cardiac function which required optimization of diuretic therapy. Patient's vital signs have remained stable, he has reported improved appetite and started to regain some of the lost weight; his electrolytes remained stable. Six-month interval imaging has shown reduction of the size of the adrenal gland sizes and no evidence of gland hemorrhage; notably, adrenal gland improvement has generally paralleled imaging improvement in other involved organs. Steroid therapy is being continued for total of 12 months. DHI still remains a serious problem in certain regions of the US and the world and has to remain an essential part of the differential diagnosis of the adrenal lesions allowing earlier treatment, gland preservation and avoidance of life-threatening complications.
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