Introduction: Adrenal tuberculosis (TB) is a rare but important cause of adrenal insufficiency in TB-endemic regions, usually secondary to pulmonary or extrapulmonary disease, with primary involvement being uncommon. It typically affects both glands via hematogenous or lymphatic spread and presents late with nonspecific features after significant adrenal destruction, making diagnosis challenging. Diagnosis is more straightforward in the presence of extraadrenal TB, where imaging may obviate the need for biopsy, but remains difficult in isolated adrenal involvement. Case: We report a 69-year-old Malay male with diabetes mellitus, hypertension, and hyperlipidemia who presented with a 2-week history of chronic cough and 4 months of constitutional symptoms, including weight loss and anorexia. Initial TB workup in September 2025 was negative. He was subsequently admitted twice in October 2025 for pneumonia, with persistent upper lobe consolidation on chest radiography despite antibiotics. Contrast-enhanced computed tomography thorax, abdomen, and pelvis revealed bilateral mildly enhancing hypodense adrenal lesions (right 3.7 × 3.0 cm, left 2.5 × 2.6 cm), suggestive of adenoma, hyperplasia, or lymphoma. Bronchoscopy detected Mycobacterium tuberculosis via GeneXpert BAL, with no malignant cells on cytology. Adrenal biopsy was non-diagnostic. Biochemical evaluation showed low morning cortisol with elevated adrenocorticotropic hormone and findings consistent with adrenal insufficiency. The patient was treated as smear-negative pulmonary TB with adrenal involvement and initiated on anti-TB therapy, currently in the maintenance phase. Hydrocortisone replacement 10 mg twice daily was also initiated. Conclusion This case highlights the diagnostic challenge of adrenal TB, particularly when tissue sampling is inconclusive. In TB-endemic settings, a presumptive diagnosis based on clinical, radiological, and microbiological evidence is often necessary. Early empiric anti-TB therapy is essential to prevent adrenal crisis and preserve endocrine function.
Tuberculosis