An unusual cause of adrenal insufficiency and bilateral adrenal masses. (6th July 2018)

• Record Type: Journal Article
• Authors: Tee, Su Ann; Gan, Earn Hui; Kanaan, Mohamad Zaher; Price, David Ashley; Hoare, Tim; Pearce, Simon H S
• Is Part Of: Endocrinology, diabetes & metabolism case reports. (2018)
• Publication Date: 2018-07-06
• Subjects: Adult -- Male -- White -- United Kingdom; Adrenal -- Adrenal -- Cortisol -- ACTH -- Aldosterone -- Adrenal insufficiency -- Bilateral adrenal hyperplasia -- Hyponatraemia -- Lymphadenopathy -- Hyperkalaemia; Lymphadenitis -- Vision - acuity reduction -- Liver masses -- Weight loss -- Anorexia -- Dizziness -- Hyponatraemia -- Hyperkalaemia -- Hypotension -- Hyperpigmentation -- Normochromic normocytic anaemia -- Urinary frequency -- Nocturia -- Adrenal antibodies -- Cortisol -- Cortisol (9am) -- ACTH stimulation -- MRI -- CT scan -- C-reactive protein -- X-ray -- Urinalysis -- Creatinine -- Urea and electrolytes -- Urine osmolality -- Serum osmolality -- Sodium -- Potassium -- Haemoglobin -- ACTH -- Aldosterone (plasma) -- Alkaline phosphatase -- Fludrocortisone -- Glucocorticoids -- Hydrocortisone -- Mineralocorticoids -- Antibiotics -- Ketoconazole; Ophthalmology; Unique/unexpected symptoms or presentations of a disease; Unique/unexpected symptoms or presentations of a disease -- July -- 2018; Endocrinology -- Periodicals; Diabetes -- Periodicals; Diabetes Mellitus; Endocrinology; Diabetes; Endocrinology; Case Reports; Periodicals; Periodicals; 616.4
• DOI: 10.1530/EDM-18-0030
• Languages: English
• ISSNs: 2052-0573

Abstract

Summary: Primary adrenal insufficiency secondary to syphilis is extremely rare, with only five cases being reported in the literature. We report a case of adrenal insufficiency as a manifestation of Treponema pallidum infection (tertiary syphilis). A 69-year-old, previously fit and well Caucasian male was found to have adrenal insufficiency after being admitted with weight loss, anorexia and postural dizziness resulting in a fall. Biochemical testing showed hyponatraemia, hyperkalaemia, and an inadequate response to Synacthen testing, with a peak cortisol level of 302 nmol/L after administration of 250 µg Synacthen. Abdominal imaging revealed bilateral adrenal hyperplasia with inguinal and retroperitoneal lymphadenopathy. He was started on hydrocortisone replacement; however, it was not until he re-attended ophthalmology with a red eye and visual loss 1 month later, that further work-up revealed the diagnosis of tertiary syphilis. Following a course of penicillin, repeat imaging 5 months later showed resolution of the abnormal radiological appearances. However, adrenal function has not recovered and 3 years following initial presentation, the patient remains on both glucocorticoid and mineralocorticoid replacement. In conclusion, this case highlights the importance of considering syphilis as a potential differential diagnosis in patients presenting with adrenal insufficiency and bilateral adrenal masses, given the recent re-emergence of this condition. The relative ease of treating infectious causes of adrenal lesions makes accurate and timely diagnosis crucial. Learning points: Infectious causes, including syphilis, should be excluded before considering adrenalectomy or biopsy for any patient presenting with an adrenal mass. It is important to perform a full infection screen including tests for human immunodeficiency virus, other blood-borne viruses and concurrent sexually transmitted diseases in patients presenting with bilateral adrenal hyperplasia with primary adrenal insufficiency. Awareness of syphilis as a potential differential diagnosis is important, as it not only has a wide range of clinical presentations, but its prevalence has been increasing in recent times.