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Symptomatic adrenal histoplasmosis – suspicion and diagnosis

July 14 2016

Adrenal histoplasmosis is uncommon but a very important diagnosis. While tuberculosis may be numerically more common, Histoplasma capsulatum is a very important differential diagnosis. Histoplasma has a remarkable predeliction for the adrenal gland, unlike any other fungi or bacteria.

Adrenal histoplasmosis is usually bilateral (1, 2). Dr Smeeta Gajendra and colleagues from Gurgaon, India describe 12 cases of adrenal histoplasmosis seen in 2 years (3). All were in immunocompetent males and occurred in a non-endemic area. They presented with nonspecific symptoms and clinical signs and all had markedly impaired adrenal insufficiency. Ten patients had bilateral involvement. 18F-FDG PET/CT in 10 patients showed high FDG uptake in the adrenals (Figure 1). All the patients had histopathological/cytological proven disease (Figure 2). Two patients had simultaneous histoplasmosis in other sites, one in the epiglottitis and the other in the alveolus.

These patients illustrate that symptomatic adrenal histoplasmosis presents with chronic fatigue, weight loss, anorexia and sometimes fever. Progressive destruction of bilateral adrenal glands occurs in only 5-71% of adrenal histoplasmosis cases, and with treatment is preventable. In these patients, who have subacute disseminated histoplasmosis, adrenal involvement is the commonest cause of (avoidable) death.

Dr Gajendra report symptomatic improvement with treatment with amphotericin B and/or itraconazole therapy in all cases.  

Original article

References:

1.       Bhansali A, Das S, Dutta P, Walia R, Nahar U, Singh SK, Vellayutham P, Gopal S. Adrenal histoplasmosis: Unusual presentations. J Assoc Physicians India. 2012; 60:54-8.

2.       Kauffman CA. Histoplasmosis: A clinical and laboratory update. Clin Microbiol Rev. 2007; 20:115-32.

3.       Gajendra S, Sharma R, Goel S, Goel R, Lipi L, Sarin H, et al. Turk Patoloji Derg. 2016; 32(2):105-111.