Chest radiographs. Figure 3. CT scan of the abdomen on coronal view showed a right adrenal gland measuring 3. Other treatments included ranitidine 50 mg intravenously two times daily, metoclopramide 10 mg intravenously three times daily and ceftriaxone 1 g intravenously two times daily.
Fludrocortisone was not available in our hospital. After serum cortisol data became available, intravenous steroid was continued and later tapered to low dose oral dexamethasone 1 mg once daily with the resolution of acute adrenal insufficiency. The patient was discharged with instructions to maintain prednisone 5 mg once daily, calcium lactate and vitamin D supplementation, anti-TB medications and vitamin B6, and to plan urologic surgery to release the urinary tract obstruction to prevent progression of chronic kidney disease.
Subsequently, he never had any recurrence of weakness. Chest radiographs, electrolytes and glucose also improved Figure 4. Depending on the acuteness of the hormonal deficit and the presence of concurrent illness, symptoms may present acutely in adrenal crisis, or insidiously.
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Our patient developed nonspecific but progressive symptoms of fatigue, weakness, weight loss, anorexia, nausea and vomiting and diarrhea, which may have delayed consult and subsequent diagnosis. He finally presented with hypotension leading to shock accompanied by hypoglycemia, which were classic signs of adrenal crisis. Routine laboratory findings revealed hyponatremia, azotemia and hypoglycemia. TB of the adrenal glands may be seen on CT scan imaging as bilateral enlargement on active infection, followed by atrophy and calcification on remote infection. We think our patient had remote infection in both adrenal glands, despite the absence of calcification.
Adrenal cysts have been reported to be caused by Echinococcus species.
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Tuberculosis of the adrenal glands leads to inflammation, necrosis and destruction of adrenal cortical tissue. In most cases, extra-adrenal TB is usually evident, but may be clinically latent. The aims of treatment are to replace the deficient hormones and treat any reversible causes of adrenal disease. However, patients usually have to maintain hormone replacement. However, if the adrenal glands are enlarged, anti-TB medications may be needed.
Over-treatment may result in hypertension and edema.
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DHEA may improve self-esteem, mood, fatigue scores, and libido, particularly in women. Correction of hyponatremia and hypoglycemia was stopped right after steroid coverage was given, with note of clinical and biochemical improvement. Dexamethasone was then tapered to 1 mg orally, and then shifted to prednisone 5 mg once daily along with anti-TB medications.
Many reports also describe the occurrence of adrenal insufficiency after the administration of rifampicin. Rifampicin facilitates the clearance of many drugs from the blood, including various glucocorticoids, via the induction of cytochrome CYP3A4, which metabolizes glucocorticoids in the liver. Our patient was also had upper and lower urinary tract infections, based on history, physical findings and urinalysis.
He received ceftriaxone as empirical treatment.
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Following urine tests indicating negative bacterial culture and positive AFB smear, urinary TB infection was considered as the cause of complicated UTI. Treatment of urinary tuberculosis includes antituberculosis treatment with rifampicin, isoniazid, pyrazinamide and ethambutol for 9 months; corticosteroid to reduce mucosal inflammation and relieve symptoms; and surgical intervention.
Since the imaging findings revealed bilateral hydroureteronephrosis and chronic cystitis, urologic surgery was planned for obstruction release, drainage of pus, evacuation of calculi, augmentation of the urinary bladder and reconstruction of the upper and lower urinary tracts to prevent the progression of CKD.
We reported a year-old male with acute adrenal insufficiency and complicated UTI caused by tuberculosis. This report highlights the importance of prompt, adequate and complete treatment of pulmonary tuberculosis, as the likelihood of progression to extrapulmonary infection is very high. In this case, involvement of the adrenal glands and the kidneys led to a life-threatening condition of adrenal crisis and chronic kidney disease.
Because of its significant impact on healthcare resources, our case underscores the importance of adequate provision of resources needed to conduct full implementation of programs for the treatment and eradication of of tuberculosis. Patient consent form has been procured prior to the case report study. All authors have given approval to the final version submitted.
Author Disclosure. All the authors declared no conflicts of interest.
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