Think Addison's Disease: Disseminated Tuberculosis Presenting With Adrenal Crisis in a Young Male Patient

A 42-year-old Indian man presented to the emergency department with hypotensive collapse, initially presumed to be septic shock. He had a background of progressive weight loss, fatigue, anaemia, and a strict vegan and lactose-free diet requiring vitamin B12 supplementation in the past. Despite fluid resuscitation and broad-spectrum antibiotics, his shock persisted. Profound hyponatremia (Na 106 mmol/L) with hyperkalaemia (K 5.6 mmol/L), diffuse skin hyperpigmentation, and lab tests showed low cortisol and clinical features of adrenal insufficiency, supported by imaging and culture-confirmed tuberculosis (TB). Further evaluation revealed disseminated TB as the underlying cause. CT imaging showed bilateral adrenal enlargement (adrenalitis) without destruction, along with cavitary pulmonary lesions, a "tree-in-bud" pattern in the lungs, lymphadenopathy, and TB foci in the bursa and scrotum. TB infection was confirmed with a positive culture. The patient was treated with high-dose intravenous hydrocortisone and fluid/electrolyte support, followed by lifelong glucocorticoid and mineralocorticoid replacement and a full course of anti-tubercular therapy. He gradually stabilised, with resolution of hypotension and electrolyte imbalances, and showed clinical improvement on follow-up. This case highlights the importance of considering adrenal crisis in refractory hypotension, particularly in younger patients, and underscores the rare presentation of early adrenal TB with preserved gland shape, demonstrating how disseminated TB, facilitated by diet-related malnutrition, can present as Addison's disease with characteristic adrenal imaging findings and increased severity.