Tran Nam Quang, Phan Chien Cong, Doan Thao Thi Phuong, Tran Thang Viet
Department of Endocrinology, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam.
Department of Imaging, University Medical Center at Ho Chi Minh City, Ho Chi Minh City, Vietnam.
Endocrinol Diabetes Metab Case Rep. 2021 Dec 1;2021. doi: 10.1530/EDM-21-0093.
Primary adrenal insufficiency is a rare disease and can masquerade as other conditions; therefore, it is sometimes incorrectly diagnosed. Herein, we reported the case of a 39-year-old Vietnamese male with primary adrenal insufficiency due to bilateral adrenal tuberculosis. The patient presented to the emergency room with acute adrenal crisis and a 3-day history of nausea, vomiting, epigastric pain, and diarrhoea with a background of 6 months of fatigue, weight loss, and anorexia. Abdominal CT revealed bilateral adrenal masses. Biochemically, unequivocal low morning plasma cortisol (<83 nmol/L) and high plasma adrenocorticotropic hormone levels were consistent with primary adrenal insufficiency. There was no evidence of malignancy or lymphoma. As the patient was from a tuberculosis-endemic area, extra-adrenal tuberculosis was excluded during the work up. A retroperitoneal laparoscopic left adrenalectomy was performed, and tuberculous adrenalitis was confirmed by the histopathological results. The patient was started on antituberculous therapy, in addition to glucocorticoid replacement. In conclusion, even without evidence of extra-adrenal tuberculosis, a diagnosis of bilateral adrenal tuberculosis is required. A histopathological examination has a significant role along with clinical judgement and hormonal workup in establishing a definitive diagnosis of adrenal tuberculosis without evidence of active extra-adrenal involvement.
Primary adrenal insufficiency can be misdiagnosed as other mimicking diseases, such as gastrointestinal illness, leading to diagnostic pitfalls. Adrenal insufficiency can be confirmed with significantly low morning plasma cortisol levels of <83 nmol/L without a dynamic short cosyntropin stimulation test. Tuberculous adrenalitis is an uncommon treatable condition; however, it remains an important cause of primary adrenal insufficiency, especially in developing countries. In the absence of extra-adrenal involvement, adrenal biopsy plays a key role in the diagnostic process. Alternatively, adrenalectomy for histopathological purposes should be considered if CT scan-guided fine needle aspiration is infeasible in cases of small adrenal masses.
原发性肾上腺皮质功能减退症是一种罕见疾病，可伪装成其他病症，因此有时会被误诊。在此，我们报告了一例39岁越南男性因双侧肾上腺结核导致原发性肾上腺皮质功能减退症的病例。该患者因急性肾上腺危象就诊于急诊室，有3天的恶心、呕吐、上腹部疼痛和腹泻病史，此前6个月有疲劳、体重减轻和厌食症状。腹部CT显示双侧肾上腺肿块。生化检查显示，明确的清晨血浆皮质醇水平低（<83 nmol/L）且血浆促肾上腺皮质激素水平高，符合原发性肾上腺皮质功能减退症。无恶性肿瘤或淋巴瘤的证据。由于患者来自结核病流行地区，在检查过程中排除了肾上腺外结核。进行了腹膜后腹腔镜左肾上腺切除术，组织病理学结果证实为结核性肾上腺炎。除糖皮质激素替代治疗外，患者开始接受抗结核治疗。总之，即使没有肾上腺外结核的证据，也需要诊断为双侧肾上腺结核。在没有肾上腺外活动性受累证据的情况下，组织病理学检查在与临床判断和激素检查一起建立肾上腺结核的明确诊断方面具有重要作用。
原发性肾上腺皮质功能减退症可能被误诊为其他类似疾病，如胃肠道疾病，导致诊断陷阱。无需进行动态短程促肾上腺皮质激素刺激试验，清晨血浆皮质醇水平显著低于83 nmol/L即可确诊肾上腺皮质功能减退症。结核性肾上腺炎是一种罕见但可治疗的病症；然而，它仍然是原发性肾上腺皮质功能减退症的重要原因，尤其是在发展中国家。在没有肾上腺外受累的情况下，肾上腺活检在诊断过程中起关键作用。或者，如果在肾上腺小肿块病例中无法进行CT引导下细针穿刺活检，则应考虑为组织病理学目的进行肾上腺切除术。
