A 48-year-old man was referred to our hospital for general malaise and anorexia. His symptoms had appeared approximately four months prior to referral. He showed freckles on his face and trunk that had been darkening every day, the occurrence of new freckles, and weight loss of 14 kg. The patient had no particular remarkable medical history or known allergies. He was not taking any medications, did not smoke or drink alcohol, and did not use any illicit drugs. His father had diabetes mellitus, and his mother had gastric cancer.
On a physical examination, the patient's weight was 56 kg, and his height was 180 cm. His blood pressure was 84/56 mmHg; pulse, 98 beats per minute; body temperature, 36.4C; respiratory rate, 16 breaths per minute; and oxygen saturation level, 99% while breathing ambient air. A skin examination revealed brown freckles mainly on his face, lip, and trunk (Fig. 1). On the neck, back of the hands, elbows, and knees, the hyperpigmentation was unremarkable. His physical examination findings were otherwise normal.
Laboratory data showed a white blood cell count of 8,200/muL, hemoglobin level of 14 g/dL, platelet count of 289,000/muL, C-reactive protein level of 2.35 mg/dL, albumin level of 3.7 g/dL, creatinine level of 0.79 mg/dL, sodium level of 121 mEq/L, potassium level of 4.9 mEq/L, fasting blood glucose level of 89 mg/dL, free thyroxine level of 1.47 ng/dL, thyroid stimulating hormone level of 2.4 muIU/mL, cortisol level of 1.0 mug/mL (normal range, 4.0-19.3 mug/mL), and adrenocorticotropic hormone (ACTH) level of 1,140 pg/mL (normal range, 7.2-63.3 pg/mL). Other test results are shown in Table.
Adrenal insufficiency was suspected on the basis of these clinical findings and laboratory data, and abdominal ultrasonography and non-contrast computed tomography (CT) were immediately performed to examine the patient's adrenal glands; these showed enlargement of the bilateral adrenal glands (Fig. 2). Chest radiography and non-contrast chest CT revealed multiple nodular shadows with cavitation in the fields of both lungs (Fig. 3). Addison's disease caused by tuberculosis and active pulmonary tuberculosis were suspected, and the patient was admitted to a quarantine room on the same day he visited our hospital.
Intravenous saline and oral hydrocortisone (20 mg/day) were administered to treat the hyponatremia and adrenal insufficiency, resulting in the marked amelioration of his symptoms, such as general malaise and anorexia, and hyponatremia. Although the first and second sputum smears yielded negative results, a third sputum smear was positive for Mycobacterium. Furthermore, a polymerase chain reaction (PCR) analysis of the third sputum sample showed Mycobacterium tuberculosis complex. In addition, a PCR analysis of his gastric juice also demonstrated Mycobacterium tuberculosis complex. The patient was therefore ultimately diagnosed with Addison's disease caused by tuberculosis and active pulmonary tuberculosis.
He was transferred to a tuberculosis hospital with a specialized quarantine ward and room for tuberculosis treatment, and a combination of four drugs (isoniazid, rifampicin, pyrazinamide, and ethambutol) was administered in addition to hydrocortisone. After the treatment, his hyperpigmentation was markedly ameliorated (Fig. 4), and he was discharged after one month of hospitalization. The patient has demonstrated no exacerbation of the hyperpigmentation or recurrence of Addison's disease caused by tuberculosis and/or active pulmonary tuberculosis since he was discharged. One year after treatment initiation, his laboratory data showed the following: sodium level, 140 mEq/L; potassium level, 5.0 mEq/L; chloride level, 102 mEq/L; and ACTH level, 454.6 pg/mL. Further, non-contrast abdominal CT revealed that the transverse diameter of the right adrenal gland had decreased from 34 mm to 29 mm, while that of the left adrenal gland had decreased from 27 mm to 22 mm.
Non-contrast chest computed tomography image. Numerous centrilobular nodules with at least one small cavity were observed in both apical lung fields.