Sohail Akhtar.
Tuberculous Addisons diseases : a diagnostic dilemma.
Pak J Chest Med Jan ;12(2):19-22.

A 65 years old male of presented with a three month history of malaise, anorexia and weight loss of 14 kg. His past history included having pulmonary Tuberculosis 30 years ago and a left pleural effusion 8 years ago. He smoked pipe and consumed approximately half an ounce of tobacco per week. On examination he looked ill with evidence of recent weight loss. His temperature was 37.4° C, chest examination revealed reduced air entry at left base. His initial investigations revealed Hemoglobin of 11.9 gm per dl, normocytic blood picture, normal white cell count, total and differential, and platelets; Erythrocyte Sedimentation Rate of 54. Chest X-ray showed atelectasis at left costophrenic angle (unchanged since 1983). Pleural aspiration was attempted twice but no fluid was aspirated. Ultrasound of abdomen was normal. Fibreoptic bronchoscopy revealed changes of chronic bronchitis only. Brush cytology was negative for any pathology. Tomogram of chest showed elliptical opacity at left base and pleural thickening at left costophrenic angle. Similar findings were seen on computed tomography (CT) scan of chest. A suspicion of tumour was made and CT guided fine needle aspiration (FNA), and later true cut biopsy of the mass was done. Histology simply showed fibrosis and chronic inflammatory cells and no malignancy. These investigations were done over ten weeks and during follow-up the patient showed no improvement in his initial complaints. He complained of inability to eat rice, lost weight further and thought his skin color especially back of hands had turned darker. He was admitted and empirical anti-tuberculous therapy (ATT) including Rifampicin, Isoniazid and Pyrazinamide was started. After 7 days he was even worse, in fact completely anorectic. His B.P. was 100/70mm Hg supine (and 90/60 erect). His serum biochemistry was deranged; sodium 126 meq/l, potassium 5.5 meq/l, urea 12.8 mmol/I, creatinine 132 mmol/l. His ATT was stopped after one week and CT scan was reviewed. In the abdominal films there was suggestion of `bulky` adrenal glands. Keeping this along with his clinical and laboratory picture, a suspicion of Adrenccortical Insufficiency was made and he was commenced on intravenous hydrocortisone 100 mg 6 hourly after taking a stat sample of blood for Cortisol. Within 24 hours, he showed dramatic improvement, started eating and drinking normally and was fully mobile in 48 hours. His blood pressure was normal and his urea, creatinine and electrolytes returned to normal in a week. Serum Cortisol level prior to steroids was 53 nmol/l at 2 PM (N: 180-600).

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