Addison’s disease due to tuberculosis of the adrenal glands

Anna Dąbrowska 1  ,  
Jerzy Tarach 1,  
Department of Endocrinology, Medical University, Lublin, Poland
Department of Internal Medicine, Medical University, Lublin, Poland
JPCCR 2012;6(2):88–92
Addison’s disease (AD), or primary adrenocortical insufficiency, was first described by Thomas Addison in patients with adrenal tuberculosis (TBC). Over the past several decades, along with the introduction of antituberculous chemotherapy, the incidence of TBC and AD have declined. The most common symptoms are non-specific and diagnosis is therefore often delayed and patients may first present with a life-threatening crisis.

To describe clinical symptoms and signs, as well as diagnosis and treatement of Addison’s disease due to adrenal tuberculosis.

State of knowledge:
At present in developed countries, about 75-80% of cases of AD are caused by autoimmune destruction, i.e. autoimmune adrenalitis, whereas TBC is the other most common cause and accounts for 7-20% of cases; however, it still remains the main cause of Addison’s disease in the developing countries. TBC is more commonly associated with the bilateral glands than the unilateral glands. CT and MR are useful to differentiate between tuberculous Addison’s disease and the other causes of adrenal insufficiency with high specificity. The CT or MR features of adrenal TBC are bilateral mass-like enlargement, peripheral rim enhancement and calcification on CT scans.

Although tuberculous Addison’s disease has been decreasing markedly in recent years, the possibility of adrenal insufficiency should be considered when hyponatremia is observed in patients with active tuberculosis, or in those having a past history of TBC. A combination of clinical symptoms, laboratory results, pathological findings and CT or MR features can help to establish a final diagnosis. Prompt treatement with antituberculous chemotherapy, biochemical monitoring of adrenal function, and appropriate steroid therapy are essential for the management of adrenal TBC which may even be reversible if detected in early stages.

Anna Dąbrowska   
Krańcowa 80/21, 20-356 Lublin, Poland
1. Addison T. On the constitutional and local effects of disease of the supra-renal capsules. London: Highley, 1855.
2. Patnaik MM, Deshpande AK. Diagnosis –Addison’s disease secondary to tuberculosis of the adrenal glands. Clin Med Res. 2008; 6(1): 29.
3. Brooke AM, Monson JP. Addison’s disease. Medicine 2009; 37(8): 416- 419.
4. Guttman PH. Addison’s disease: a statistical analysis of 566 cases and study of the pathology. Arch Path. 1930; 10: 742-785.
5. Kinjo T, Higuchi D, Oshiro Y, Nakamatsu Y, Fujita K, Nakamoto K, et al. Addison’s disease due to tuberculosis that required differentiation from SIADH. J Infect Chemother. 2009; 15(4): 239-242.
6. Lam KY, Lo CY. A critical examination of adrenal tuberculosis and a 28-year autopsy. Clin Endocrinol. (Oxf) 2001; 54(5): 633-639.
7. Ma ES, Yang ZG, Li Y, Guo YK, Deng YP, Zhang XC. Tuberculous Addison’s disease: Morphological and quantitative evaluation with multidetector-row CT. Eur J Radiol. 2007; 62(3): 352-358.
8. Yokoyama T, Toda R, Kimura Y, Mikagi M, Aizawa H. Addison’s disease induced by miliary tuberculosis and the administration of rifampicin. Inter Med. 2009; 48(15): 1297-1300.
9. Zhang XC, Yang ZG, Li Y, Min PQ, Guo YK, Deng YP, et al. Addisons disease due to adrenal tuberculosis: MRI features. Abdom Imaging 2008; 33(6): 689-694.
10. Nomura K, Demura H, Saruta T. Addison’s disease in Japan: characteristics and changes revealed in a nationwide survey. Intern Med. 1994; 33(10): 602-606.
11. Bhatia E, Jain SK, Gupta RK, Pandey R. Tuberculous Addison’s disease: lack of normalization of adrenocortical function after anti-tuberculous chemotherapy. Clin Endocrinol. (Oxf) 1998; 48(3): 355-359.
12. Guo YK, Yang ZG, Li Y, Ma ES, Deng YP, Min PQ, et al. Addison’s disease due to adrenal tuberculosis: contrast-enhanced features and clinical duration correlation. Eur J Radiol. 2007; 62(1): 126-131.
13. Rowińska-Zakrzewska E, Szopiński J, Remiszewski P, Szymański D, Miller P, Pawlicka L, et al. Tuberculosis in the autopsy material: analysis of 1500 autopsies performed between 1972 and 1991 in the Institute of Tuberculosis and Chest Diseases, Warsaw, Polnad. Tuber Lung Dis. 1995; 76(4): 349-354.
14. Soule S. Addison;s disease in Africa- a teaching hospital experience. Clin Endocrinol. (Oxf) 1999, 50(1): 115-120.
15. Jacobi J, Schnellhardt S, Kulschewski A, Amann KU, Kuefner MA, Eckardt KU, et al. An unusual case of hyponatraemia. Nephrol Dial Transplant. 2010; 25(3): 998-1001.
16. Dorin RI, Qualls CR, Crapo LM. Diagnosis of adrenal insufficiency. Ann Intern Med. 2003; 139(3):194-204.
17. Alevritis EM, Sarubbi FA, Jordan RM, Peiris AN. Infectious causes of adrenal insufficiency. South Med J. 2003; 96(9): 888-891.
18. Penrice J, Nussey SS. Recovery of adrenocortical function following treatement of tuberculosis Addison’s disesase. Postgrad Med J. 1992; 68(797): 204-205.
19. Kelestimur F. Recovery of adrenocortical function following treatment of tuberculous Addison’s disease. Postgrad Med J. 1993; 69(816): 832- 834.
20. Edwards OM, Courtenay-Evans RJ, Galley JM, Hunter J, Tait AD. Changes in cortisol metabolism following rifampicin therapy. Lancet 1974; 2(7880): 548-551.
21. Kolars JC, Schmiedlin-Ren P, Schuetz JD, Fang C, Watkins PB. Identification of rifampin-inducible P450IIIA4 (CYP3A4) in human small bowel enterocytes. J Clin Invest. 1992; 90(5):1871-1878.
22. Efremidis SC, Harsoulis F, Douma S, Zafiriadou E, Zamboulis C, Kouri A. Adrenal insufficiency with enlarged adrenals. Abdom Imag. 1996; 21(2):168-171.
23. Wang YX, Chen CR, He GX, Tang AR. CT findings of adrenal glands in patients with tuberculous Addison’s disease. J Belge Radiol. 1998; 81(5): 226-228.
24. Yang ZG, Guo YK, Li Y, Min PQ, Yu JQ, Ma ES. Differentiation between tuberculosis and primary tumors in the adrenal gland: evaluation with contrast-enhanced CT. Eur Radiol. 2006; 16(9): 2031-2036.
25. Kelestimur F, Unlu Y, Ozesmi M, Tolu 1. A hormonal and radiological evaluation of adrenal gland in patients with acute and chronic pulmonary tuberculosis. Clin Endocrinol. (Oxf) 1994; 41(1): 53-56.
26. Mantzios G, Tsirigotis P, Veliou F, Boutsikakis I, Petraki L, Kolovos J, et al. Primary adrenal lymphoma presenting as Addison’s disease: case report and review of the literature. Ann Hematol. 2004; 83(7): 460-463.
27. Cirillo Jr RL, Bennett WF, Vitellas KM, Poulos AG, Bova JG. Pathology of the adrenal gland: imaging features. AJR Am J Roentgenol. 1998; 1(2): 429-435.
28. Kumar N, Singh S, Govil S. Adrenal histoplasmosis: clinical presentation and imaging features in nine cases. Abdom Imag. 2003; 28(5): 703-708.
29. Lio S, Cibin M, Marcello R, et al. Adrenal bilateral incidentaloma by reactivated histoplasmosis. J Endocrinol Invest. 2000; 23: 476-479.
30. Fan ZM, Zeng QY, Huo JW, Bai L, Liu ZS, Luo LF, et al. Macronodular multiorgans tuberculoma: CT and MR appearances. Gastroenterol. 1998; 33(2): 285-288.
31. Murata Y, Yamada I, Sumiya Y, Shichijo Y, Suzuki Y. Abdominal macronodular tuberculomas: MR findings. J Comput Assist Tomogr. 1996; 20(4): 643-646.