Addisonian crisis and tuberculous epididymo-orchitis.
OBJECTIVE
To describe a case of acute primary adrenal insufficiency in which tuberculosis was subsequently detected as the etiologic factor when the patient presented with tuberculous epididymo-orchitis.


METHODS
A case of acute primary adrenal insufficiency associated with bilaterally enlarged adrenal glands is reported, along with the subsequent finding of a scrotal mass diagnosed as tuberculous epididymo-orchitis. Diagnosis, adrenal function, and results of imaging studies after institution of antituberculous treatment are discussed.


RESULTS
A 41-year-old Egyptian man, who had immigrated to the United States 5 years previously, had acute psychosis and addisonian crisis. A substantially increased early morning level of plasma adrenocorticotropic hormone and a low level of serum cortisol confirmed the diagnosis of primary adrenal insufficiency. Both adrenal glands were enlarged but without calcification on computed tomography. A previous bacille Calmette-Guérin vaccination complicated the interpretation of a positive tuberculin skin test result. Both lungs were clear on chest radiography and computed tomography. Seven months later, the patient had a left scrotal mass and underwent radical orchiectomy. Examination of the pathology specimen showed caseous granulomatous inflammation and necrosis, and acid-fast bacilli were identified. Culture was positive for Mycobacterium tuberculosis.


CONCLUSIONS
In a patient from a country where tuberculosis is endemic, tuberculosis should be considered in the differential diagnosis when primary adrenal insufficiency is detected, especially in association with enlarged or calcified adrenal glands. Extra-adrenal tuberculous involvement should be actively sought because it may provide indirect microbiologic or histologic clues. Other than the lungs, special attention should be paid to the genitourinary system.
Kon
Yin Chian
YC
Department of Medicine, University of Chicago, Illinois 60637, USA.
Sokoloff
Mitchell
M
Straus
Francis H
FH
Weiss
Roy E
RE
D000224:Addison Disease / Q000382:microbiology*; D000311:Adrenal Glands / Q000000981:diagnostic imaging / Q000473:pathology; D000309:Adrenal Insufficiency / Q000175:diagnosis / Q000382:microbiology* / Q000473:pathology; D000324:Adrenocorticotropic Hormone / Q000097:blood; D000328:Adult; D004534:Egypt / Q000208:ethnology; D004823:Epididymitis / Q000382:microbiology*; D006801:Humans; D006854:Hydrocortisone / Q000097:blood; D008297:Male; D009169:Mycobacterium tuberculosis / Q000302:isolation & purification; D009919:Orchiectomy; D009920:Orchitis / Q000382:microbiology*; D013737:Testis / Q000000981:diagnostic imaging; D014057:Tomography, X-Ray Computed; D014376:Tuberculosis / Q000175:diagnosis*; D014463:Ultrasonography; D014481:United States
D000324:Adrenocorticotropic Hormone; D006854:Hydrocortisone