Reemergence of tuberculosis with adrenal and cutaneous manifestations 12 years after declared cure

¹Department of Endocrinology, Diabetology, Metabolic Diseases and Nutrition, Mohammed VI University Hospital, Marrakesh, Morocco

^&Corresponding author
Meryam Alahyane, Department of Endocrinology, Diabetology, Metabolic Diseases and Nutrition, Mohammed VI University Hospital, Marrakesh, Morocco

Image in medicine    

A 65-year-old woman with a history of pulmonary tuberculosis, successfully treated 12 years ago, presented with altered consciousness and severe hyponatremia (100 mmol/L), accompanied by generalized melanodermia. These findings revealed primary acute adrenal insufficiency, confirmed by a reduced plasma cortisol level of 3 µg/dL and an elevated ACTH level of 153 ng/L. Computed tomography showed calcified bilateral adrenal masses, measuring 20 mm on the left side and 16 mm on the right side, with a spontaneous density of 33 Hounsfield units and a maximal absolute washout value of 27% on the left adrenal mass (A). These findings suggested adrenal tuberculosis relapse as the underlying cause of adrenal insufficiency. In addition to adrenal involvement, the patient presented with a right temporal skin lesion, clinically suggestive of lupus vulgaris (B). A biopsy revealed giant epithelioid cell granulomas without caseation (C), and Gene-Xpert testing confirmed Mycobacterium tuberculosis. Serologies for sexually transmitted infections were negative. A diagnosis of polyfocal tuberculosis recurrence, involving adrenal and cutaneous sites, was identified. The systemic clinical symptoms gradually improved after correction of electrolyte imbalances along with hydrocortisone replacement therapy. The cutaneous lesion completely resolved after six months of standard tuberculosis protocol therapy (D).

Figure 1: A) axial section of computed tomography showing bilateral adrenal masses with calcifications, measuring 20 mm on the left and 16 mm on the right; the masses exhibit a spontaneous density of 33 Hounsfield units, with absolute washout values of 27% and 11%, respectively; B) erythematous, squamous plaque with areas of crusting, extending over the right temporal region, characteristic of lupus vulgaris; C) histological examination of the skin lesion biopsy revealing giant epithelioid cell granulomas without caseation; D) complete resolution of the cutaneous lesion after six months of standard tuberculosis protocol therapy