Addisonian crisis and tuberculous epididymo-orchitis

To describe a case of acute primary adrenal insufficiency in which tuberculosis was subsequently detected as the etiologic factor when the patient presented with tuberculous epididymo-orchitis.

A case of acute primary adrenal insufficiency associated with bilaterally enlarged adrenal glands is reported, along with the subsequent finding of a scrotal mass diagnosed as tuberculous epididymo-orchitis. Diagnosis, adrenal function, and results of imaging studies after institution of antituberculous treatment are discussed.

A 41-year-old Egyptian man, who had immigrated to the United States 5 years previously, had acute psychosis and addisonian crisis. A substantially increased early morning level of plasma adrenocorticotropic hormone and a low level of serum cortisol confirmed the diagnosis of primary adrenal insufficiency. Both adrenal glands were enlarged but without calcification on computed tomography. A previous bacille Calmette-Guérin vaccination complicated the interpretation of a positive tuberculin skin test result. Both lungs were clear on chest radiography and computed tomography. Seven months later, the patient had a left scrotal mass and underwent radical orchiectomy. Examination of the pathology specimen showed caseous granulomatous inflammation and necrosis, and acid-fast bacilli were identified. Culture was positive for Mycobacterium tuberculosis.

In a patient from a country where tuberculosis is endemic, tuberculosis should be considered in the differential diagnosis when primary adrenal insufficiency is detected, especially in association with enlarged or calcified adrenal glands. Extra-adrenal tuberculous involvement should be actively sought because it may provide indirect microbiologic or histologic clues. Other than the lungs, special attention should be paid to the genitourinary system.