Clinical, biochemical and imaging characteristics of adrenal histoplasmosis in immunocompetent patients in a non-endemic area: A case series
Sharmin Jahan1, Tahseen Mahmood2, Md Fariduddin1, Ibrahim Faisal3, Md Shahed Morshed4, Anil Yadav5, Anil Kumar Shah6, Chomon Abdullah1, Emran-Ur-Rashid Chowdhury1, Ferdousi Begum7, MA Hasanat1
1 Department of Endocrinology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
2 Department of Endocrinology, Combined Military Hospital, Dhaka Cantonment, Dhaka, Bangladesh
3 Division of Endocrinology, Department of Internal Medicine, Indira Gandhi Memorial Hospital, Kanbaa Aisa Rani Higun, Malé- 20402, Republic of Maldives
4 Department of Emergency, Kurmitola General Hospital, Dhaka, Bangladesh
5 Division of Endocrinology, Department of Internal Medicine, Birat Medical College Teaching Hospital, Biratnagar, Nepal
6 Division of Endocrinology, Department of Internal Medicine, Chitwan Medical College, Chitwan 44300, Nepal
7 Department of Pathology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
Department of Endocrinology, Bangabandhu Sheikh Mujib Medical University, Dhaka
Source of Support: None, Conflict of Interest: None
Objective: To document the clinical, biochemical and imaging phenotypes of immunocompetent patients with adrenal histoplasmosis.
Methods: The clinical, biochemical and radiologic data of 18 immunocompetent patients [age: 45.00 (39.25, 56.25) years, median (IQR), m/f (16/2)] with adrenal histoplasmosis presenting in the Department of Endocrinology, BSMMU between 2014 and 2020 were retrospectively analyzed.
Results: All patients were seronegative for HIV infection, and 27.8% (5/18) had well controlled diabetes mellitus. The median duration of the symptoms was 6.00 (IQR: 4.00, 11.25) months. All had significant weight loss, anorexia and weakness. Fever was present in 61.1% (11/18) patients and night sweat was present in 27.8% (5/18) cases. Hypotension and hyperpigmentation were present in 55.6% (10/18) and 66.7% (12/18) cases, respectively. Three of 18 patients presented with adrenal crisis. Hyponatremia occurred in 55.6% (10/18) cases, but none had hyperkalemia. Thirteen of 18 patients had adrenal insufficiency whereas 83.3% (15/18) had high adrenocorticotropic hormone. CT scan revealed bilateral adrenal enlargement in all cases with oval shape and regular margin. All were hypodense having radiodensity 21-90 hounsfield unit, and 11.1% (2/18) were heterogeneous in contrast enhancement. None had noticeable calcification whereas 1.1% (2/18) cases had central necrosis with peripheral rim enhancement. Hepatomegaly was present in 6 cases, splenomegaly in 3 cases and 5 patients had abdominal lymphadenopathy. Histoplasmosis were confirmed by positive fine needle aspiration cytology of adrenal tissue.
Conclusions: Adrenal histoplasmosis should be considered in the list of differentials of bilateral adrenomegaly in immunocompetent individuals even living in non-endemic areas.