A 17-year-old male with an unusual case of peritonitis

Ronik Kanani; Aleixo Muise

doi:10.1503/cmaj.1031585

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Aleixo M Muise

Posted on: 03 August 2004
TB and Adrenal Insufficiency
Wael M R Haddara and Stan H. M. van Uum

Posted on: 16 June 2004

Posted on: (3 August 2004)
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Response to letter
Aleixo M Muise
TB and ADRENAL INSUFFICIENCY
We thank Drs Wael M.R. Haddara and Stan H.M. van Uum for their interest in this case of a boy with abdominal TB1. Although tuberculosis is one of the leading causes of adrenal insufficiency in the world and should be considered in patients presenting in shock and a history suggestive of TB2, in this case the index of suspicion for adrenal insufficiency was quite low. Although our pa...
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TB and ADRENAL INSUFFICIENCY
We thank Drs Wael M.R. Haddara and Stan H.M. van Uum for their interest in this case of a boy with abdominal TB1. Although tuberculosis is one of the leading causes of adrenal insufficiency in the world and should be considered in patients presenting in shock and a history suggestive of TB2, in this case the index of suspicion for adrenal insufficiency was quite low. Although our patient was initially hypotensive his blood pressure did respond to fluids and his initial electrolytes were normal. Patients with adrenal crises usually require steroid treatment and do not easily respond to fluids. Furthermore, our patient had multiple CT scans of the abdomen, all of which showed normal adrenal glands. We did not check a cortisol level, or do an ACTH stimulation test as it was extremely unlikely that the patient had adrenal insufficiency. However, we thank Haddara and van Uum for illustrating this important point. Thank you again for your comment. Ronik Kanani & Aleixo Muise Department of Paediatrics Hospital for Sick Children Toronto, Ontario
Kanani R, Muise A. A 17-year-old male with an unusual case of peritonitis. CMAJ 2004:170(10):1541
Arlt W, Allolio B. Adrenal Insufficiency. Lancet 2003; 361: 1881-93
Conflict of Interest:
None declared
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Competing Interests: None declared.
Posted on: (16 June 2004)
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TB and Adrenal Insufficiency
Wael M R Haddara and Stan H. M. van Uum
Dear Sir
Kanani and Muise describe a case of intra-abdominal peritonitis associated with abdominal pain and hypotension secondary to intra- abdominal tuberculosis(1). We note that the clinical presentation is suspicious for adrenal insufficiency (AI).
Tuberculosis remains one of the leading causes of AI worldwide. When tuberculosis is present, it may be difficult to diagnose. Lam and colleagues conduct...
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Dear Sir
Kanani and Muise describe a case of intra-abdominal peritonitis associated with abdominal pain and hypotension secondary to intra- abdominal tuberculosis(1). We note that the clinical presentation is suspicious for adrenal insufficiency (AI).
Tuberculosis remains one of the leading causes of AI worldwide. When tuberculosis is present, it may be difficult to diagnose. Lam and colleagues conducted a retrospective survey and found active tuberculosis in 6.5% in a large series of autopsies in Hong Kong. More than 70% of those patients were diagnosed only at autopsy(2). AI was found in 6% of patients with active tuberculosis.
Tuberculosis as a cause for AI may be difficult to diagnose, as illustrated by Serter and colleagues who reported a case of a 61-year old man with AI and an adrenal mass. While tuberculin skin test, staining for acid fast bacilli and TB cultures were negative, only histology following adrenalectomy confirmed the diagnosis(3).
In patients presenting with shock and risk factors for tuberculosis it is important to maintain a high index of suspicion for AI. Where in doubt, administration of a stress dose of steroids, while awaiting results of ACTH and cortisol measurements, may be life saving.
1. Kaise R. and Muise A. A 17-year-old male with an unusual case of peritonitis CAMJ 2004; 170 (10): 1541
2. Lam KY, Lo CY. A critical examination of adrenal tuberculosis and a 28-year autopsy experience of active tuberculosis. Clin Endocrinol (Oxf). 2001 May;54(5):633-9.
3. Serter R, Koc G, Demirbas B, Culha C, Ongoren AU, Ustun H, Aral Y. Acute adrenal crisis together with unilateral adrenal mass caused by isolated tuberculosis of adrenal gland. Endocr Pract. 2003 Mar- Apr;9(2):157-61.
Wael M R Haddara, MD FRCPC and Stan H.M. van Uum, MD,PhD
Conflict of Interest:
None declared
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Competing Interests: None declared.