TB and adrenal insufficiency

Ronik Kanani and Aleixo Muise1 describe a case of intra-abdominal peritonitis associated with abdominal pain and hypotension secondary to intra-abdominal tuberculosis (TB). The clinical presentation in this case is suspicious for adrenal insufficiency.

TB is one of the leading causes of adrenal insufficiency worldwide, but the presence of TB may be difficult to diagnose. In a large retrospective study of autopsy results in Hong Kong, Lam and Lo2 found active TB in 6.5% of cases; however, in more than 70% of these patients, TB was diagnosed only at autopsy. Adrenal insufficiency was found in 6% of the patients with active TB.

It may also be difficult to identify TB as the cause of adrenal insufficiency, as illustrated by Serter and associates.3 These authors described a 61-year-old man with adrenal insufficiency and an adrenal mass. The results of tuberculin skin testing, staining for acid-fast bacilli and culture were all negative; only histologic examination after adrenalectomy confirmed the diagnosis of TB.

In patients presenting with shock and risk factors for TB it is important to maintain a high index of suspicion for adrenal insufficiency. When in doubt, administration of a stress dose of steroids while awaiting the results of corticotropin (ACTH) and cortisol measurement may save the patient's life.

Wael M.R. Haddara Stan H.M. van Uum Division of Endocrinology and Metabolism University of Western Ontario London, Ont.