Pasaribu Meilani Yevista Debora Br, Novida Hermina
Department of Internal Medicine, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia.
Department of Internal Medicine, Faculty of Medicine-Universitas Airlangga, Surabaya, Indonesia.
IDCases. 2025 Jul 9;41:e02319. doi: 10.1016/j.idcr.2025.e02319. eCollection 2025.
Secondary adrenal insufficiency (SAI) presents with non-specific clinical symptoms, which may overlap with those of HIV and tuberculosis, making diagnosis challenging. We report a case of a 22-year-old Indonesian man, presented with fatigue, intermittent dyspnea, intermittent nocturnal fever, and a significant weight loss of 5 kg over one month. He also reported having unprotected sex with a casual partner. Physically, he presented pale and weak with hypotension . Laboratory examination showed cortisol levels of 28.46 nmol/L and adrenocorticotropic hormone (ACTH) levels of 5.6 µg/dL. Chest x-ray and GeneXpert confirmed pulmonary tuberculosis. Despite an initial negative HIV examination, repeat testing was recommended due to the possibility of a false-negative result. Therefore, the initial diagnosis was SAI due to HIV and tuberculosis. He was treated with hydrocortisone and supportive therapy. Following outpatient discharge, he was re-admitted due to severe headaches, vomiting, and a generalized tonic-clonic seizure. Neuroimaging revealed ring-enhancing lesions, and serology testing was positive for toxoplasmosis IgG and IgM. Repeat testing of HIV was positive with very lowCD4 count. The final diagnosis was cerebral toxoplasmosis, newly diagnosed HIV, and disseminated tuberculosis infection. He responded well to the treatment for 20 days without any complaints and was discharged with anti-retroviral (ARV) and anti-tuberculosis drug (ATD) alongside toxoplasmosis treatment. He remained clinically stable at a 5-months follow-up. Early recognition and treatment of SAI to prevent life-threatening complications, particularly in patients with HIV and tuberculosis co-infection. Thus, early recognition and management are critical to minimize severe complications, particularly cerebral toxoplasmosis.
继发性肾上腺功能不全（SAI）表现为非特异性临床症状，可能与HIV和结核病的症状重叠，这使得诊断具有挑战性。我们报告一例22岁印度尼西亚男性病例，该患者出现疲劳、间歇性呼吸困难、间歇性夜间发热，且在一个月内体重显著减轻5千克。他还报告与一名临时伴侣有过无保护性行为。体格检查显示，他面色苍白、身体虚弱且伴有低血压。实验室检查显示皮质醇水平为28.46纳摩尔/升，促肾上腺皮质激素（ACTH）水平为5.6微克/分升。胸部X光和GeneXpert检测确诊为肺结核。尽管最初的HIV检测结果为阴性，但由于存在假阴性结果的可能性，建议进行重复检测。因此，初步诊断为因HIV和结核病导致的SAI。他接受了氢化可的松治疗和支持性治疗。门诊出院后，他因严重头痛、呕吐和全身性强直阵挛发作再次入院。神经影像学检查发现环形强化病灶，血清学检测显示弓形虫IgG和IgM呈阳性。HIV重复检测呈阳性，CD4计数极低。最终诊断为脑弓形虫病、新诊断的HIV感染和播散性结核感染。他对治疗反应良好，20天内无任何不适主诉，出院时同时接受抗逆转录病毒（ARV）药物、抗结核药物（ATD）以及弓形虫病治疗。在5个月的随访中，他的临床症状保持稳定。早期识别和治疗SAI以预防危及生命的并发症，尤其是在HIV和结核病合并感染的患者中。因此，早期识别和管理对于将严重并发症（尤其是脑弓形虫病）降至最低至关重要。
