Disseminated cryptococcosis associated with adrenal masses and insufficiency

A case of primary adrenal insufficiency with bilateral adrenal masses and meningitis due to disseminated cryptococcosis in a patient with mild non-insulin-dependent diabetes is presented. The diagnosis was made by fine-needle aspiration biopsy cytology. Although the meningitis responded to antifungal therapy, the bilateral adrenal gland enlargement did not change. Reflecting this, cryptococcal antigen titers became negative in CSF, but fell to 1:8 in serum. Although antifungal therapy continued, cryptococcal antigen titer increased both in CSF and serum for 50 days. Because the adrenal glands were the apparent focus for the persistent fungemia, bilateral adrenalectomy was performed. Antifungal therapy for an additional 15 months was needed to achieve negative serum cryptococcal antigen titers. Although adrenal insufficiency due to disseminated cryptococcosis is rare in healthy hosts, it should be included in differential diagnosis of unilateral and bilateral adrenal masses.