Disseminated Histoplasmosis Presenting as Addisonian Crisis: A Diagnostic Mimic of Tuberculosis With Bilateral Adrenal Masses
https://doi.org/10.15605/jafes.041.S1
- Author:
Aminuddin Baki Amran
1
;
Nur Aini Eddy Warman
1
;
Aimi Fadilah Mohamad
1
;
Nur Haziqah Baharum
1
;
Mohd Hazriq Awang
1
;
Fatimah Zaherah Mohamed Shah
1
;
Rohana Abdul Ghani
1
Author Information
1. Department of Internal Medicine, Faculty of Medicine, Universiti Teknologi MARA
- Publication Type:Journal Article
- MeSH:
Histoplasmosis;
Tuberculosis
- From:
Journal of the ASEAN Federation of Endocrine Societies
2026;41(S1):22-23
- CountryPhilippines
- Language:English
-
Abstract:
Introduction:Disseminated histoplasmosis is a rare but important cause
of adrenal insufficiency (AI), particularly in tuberculosis
(TB)-endemic regions, where it may mimic granulomatous
diseases. Adrenal involvement occurs in up to 80% of
disseminated cases, although overt AI is less common.
Reported cases described bilateral adrenal masses
mimicking malignancy or TB, even in immunocompetent
individuals. Addisonian crisis may be the initial
manifestation, especially when the diagnosis is delayed. In
TB-endemic settings, fungal infections are often overlooked,
leading to delayed diagnosis and inappropriate therapy.
Case:We reported a case of a 68-year-old male with underlying
diabetes mellitus who presented with fever, cough,
dysphagia, and weight loss for 1 month. He was
empirically treated as smear-negative disseminated TB.
On day 2 of therapy, he developed hypotension (80/50
mmHg), hypoglycemia (3.9 mmol/L), hyponatremia
(Na 129 mmol/L), and hyperkalemia (K 5.1 mmol/L),
suggestive of adrenal crisis, and was started on intravenous
hydrocortisone. Serum cortisol prior to treatment was 61 nmol/L. Computed tomography (CT) imaging revealed
bilateral lipid-poor adrenal lesions (right: 3.6 × 2.2 × 4.9 cm,
Hounsfield Unit (HU) 36 and absolute washout 33%; left:
3.5 × 2.4 × 5.4 cm; HU 35 and absolute washout 17%),
raising suspicion of infectious or malignant etiologies.
Endoscopic ultrasound-guided biopsy demonstrated
necrotizing granulomatous inflammation with budding
fungal yeasts on Pituitary Apoplexy Score and GMS
staining, consistent with Histoplasma capsulatum. TB and
malignancy were excluded. He received amphotericin B for
14 days, followed by oral itraconazole for 1 year, and oral
hydrocortisone replacement. At 1-year follow-up, adrenal
lesions remained stable on CT images, and he continued
to require hydrocortisone replacement.
Conclusion:This case highlights the importance of considering
disseminated histoplasmosis as a differential diagnosis
of bilateral adrenal masses with AI, especially with poor
response to anti-TB therapy. Early tissue diagnosis is
essential, as imaging findings are non-specific. Prompt
recognition is critical to prevent life-threatening adrenal
crisis and improve clinical outcomes.
- Full text:2026072813280188452EP_A010.pdf
