title: Addisonian crisis and tuberculous epididymo-orchitis.
abstract: 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.
authors.affiliation: Department of Medicine, University of Chicago, Illinois 60637, USA.
authors.forename: Yin Chian
authors.initials: YC
authors.lastname: Kon
authors.forename: Mitchell
authors.initials: M
authors.lastname: Sokoloff
authors.forename: Francis H
authors.initials: FH
authors.lastname: Straus
authors.forename: Roy E
authors.initials: RE
authors.lastname: Weiss
mesh_terms: 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
chemical_list: D000324:Adrenocorticotropic Hormone; D006854:Hydrocortisone