Age: 46.0
Sex: M
Vaccine: BCG
Symptoms: Mycobacterium test positive, Nail pigmentation, Peritoneal fluid analysis abnormal, Primary adrenal insufficiency, Salt craving
Clinical narrative: Information has been received from a published literature article. The article discusses infections of the adrenal glands remain an important cause of insufficiency, especially in the developing world. Indeed, when person first described the condition that now bears his name over 150 years ago, the vast majority of cases were attributable to tuberculosis. Here we describe a classic, but relatively uncommon, presentation of adrenal insufficiency followed by a review of the current literature pertaining to adrenal infections. This literature marketed report as received from a other health professional refers to a 46 year old male patient. Patient had a 3 month history of generalized weakness and 15-pound unintentional weight loss. He also reported mild dyspnea on exertion and decreased appetite. His past medical history was significant for hypertriglyceridemia, primary hypothyroidism, and vitamin D deficiency. Patient denied sick contacts, specifically exposure to tuberculosis, smoking, alcohol consumption, or the use of illicit substances. On an unknown date the patient started therapy with BCG vaccine. On an unknown date in 2007 tuberculin skin test performed, resulted in induration (diameter unknown) and it was attributed to prior BCG vaccine. There was no evidence of pulmonary tuberculosis on a chest radiograph. On an unknown date physical examination revealed abdominal distension and free fluid but was otherwise unremarkable. A diagnostic paracentesis revealed an exudative effusion with a positive Ziehl Neelsen stain for acid fast bacilli (vaccination failure and tuberculosis). On an unknown date patient started treatment with (Isoniazid, rifampicin, pyrazinamide, and ethambutol) for presumed extrapulmonary tuberculosis which was later confirmed by culture. One month after starting antitubercular therapy patient was presented to the hospital with worsening fatigue, salt craving, vomiting, loss of libido, and erectile dysfunction. On examination, he had low blood pressure and appeared cachectic. The patient had bitemporal muscle wasting and hyperpigmentation of skin, oral mucosa, and nails. Laboratory evaluation was significant for hyponatremia, hyperkalemia, and mild hypercalcemia. A random cortisol was 2.5 mcg/dL with an ACTH of 531.2 pcg/mL. The basal and cosyntropin stimulated serum cortisol were, respectively 1.8 mcg/dL and 2.0 mcg/dL, which was consistent with the diagnosis of primary adrenal insufficiency most likely due to tuberculosis. A computed tomography scan of the abdomen with intravenous contrast revealed bilaterally enlarged adrenal glands (4 cm x 3.3 cm on the right, 2.3 cm x 2.1 cm on the left). Patient's prior CT scan of the abdomen revealed the patient had bilaterally enlarged adrenal glands at the time of his initial presentation as well. A study that looked at tuberculosis patients with bilaterally enlarged adrenal glands found that treatment with antituberculosis drugs does not improve or help recover adrenal functionality. The outcome of vaccination failure was unknown. The reporter considered vaccination failure and tuberculosis to be related to BCG vaccine. Additional information has been requested.