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Journal Pre-Proof: AACE Clinical Case Reports
Journal Pre-Proof: AACE Clinical Case Reports
Journal Pre-Proof: AACE Clinical Case Reports
Anwar Hussain, MD, Senior Registrar, Kripa Elizabeth Cherian, MD, DM, DNB
(Endo), Associate Professor, Nitin Kapoor, MD, DM, PhD, Professor, Anne Jennifer
Prabhu, MD, Professor, Thomas V. Paul, MD, DNB (Endo), PhD (Endo), Professor
PII: S2376-0605(21)00046-8
DOI: https://doi.org/10.1016/j.aace.2021.03.006
Reference: ACCR 90
Please cite this article as: Hussain A, Cherian KE, Kapoor N, Prabhu AJ, Paul TV, Adrenal
histoplasmosis- A therapeutic restoration of adrenal morphology, AACE Clinical Case Reports (2021),
doi: https://doi.org/10.1016/j.aace.2021.03.006.
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Authors:
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Nitin Kapoor* MD, DM, PhD Professor
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Anne Jennifer Prabhu** MD Professor
Thomas V. Paul* -p
MD, DNB (Endo), PhD (Endo) Professor
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India
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Support was obtained from any grants, fellowships, and gifts of materials - NONE
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Acknowledgments -NONE
Corresponding Author
Dr Nitin Kapoor
Tel: +91-416-2282528
E-mail: nitin.endocrine@gmail.com
Adrenal histoplasmosis- A therapeutic restoration of adrenal morphology
A 42 year old male presented with generalized weakness, easy fatigability, hyperpigmentation,
low appetite and significant weight loss of 10 kg and low grade fever over the last 6 months. He
did not have cough, abdominal pain or vomiting. He was known to have hypertension since 5
years but did not require his anti-hypertensive medications since 2 months in view of normal
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blood pressure values. General examination revealed hyperpigmentation on knuckles, oral
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mucosa and palmar creases. Systemic examination was unremarkable. Patient had a serum
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sodium of 128 mmol/L, serum potassium of 5.2 mmol/L along with a serum cortisol (8 am) of
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4.55 mcg/dL. His plasma ACTH was 174 pg/ml. Following an ACTH stimulation test, the serum
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cortisol was 7.5 mcg/dL. Other investigations including complete blood count, and liver function
test were normal. The Chest X-ray was normal. Patient underwent a CT(Computed tomography)
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scan of abdomen (Figure-1). Based on the findings showed in figure-1, a CT guided biopsy was
done and histopathology is shown in Figure-2. Patient was started on treatment and there was
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Discussion:
The weight loss, hyperpigmentation and normalization of blood pressure was suggestive of
primary adrenal insufficiency. This was confirmed biochemically with presence of hyponatremia,
hyperkalemia, hypocortisolemia with an elevated plasma ACTH level. CT Abdomen (Figure-1)
revealed homogenous enlargement of bilateral adrenal glands. Biopsy of the right adrenal
the biopsy specimen confirmed histoplasma capsulatum. Acid fast bacilli culture was negative.
Patient was started on prednisolone (5 mg/day), fludrocortisone (50 mcg/day) and Itraconazole
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On follow up at 12 months patient regained the lost weight and imaging revealed a marked
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decrease in the size of adrenal mass, though still not normal when compared to the crus of the
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diaphragm. (Figure-2) The patient was continued on anti-fungal therapy and steroid
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replacements and asked to review after six months.
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involvement is seen in disseminated disease but sometimes it may be the only site of
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systemic antifungal therapy - ketoconazole or itraconazole for mild to moderate forms and
amphotericin B for severe infections[3]. Though the duration antifungal therapy is about 12-18
months in different cohorts, there is a high relapse rate of about 7.5%. [4] However, most
References
and Morphological Spectrum of Histoplasmosis on Cytology Along with the Review of Literature.
4. Singh M, Chandy DD, Bharani T, Marak RSK, Yadav S, Dabadghao P, Gupta S, Sahoo SK,
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retrospective follow-up study of 40 patients. Clin Endocrinol (Oxf). 2019 Apr;90(4):534-541.
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Conflict of Interest
AW,KEC,NK,AJP and TVP declare that they have no conflict of interest pertaing to this manuscript
Nitin Kapoor
Corresponding Author
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