A 36 year old male from Asian origin presented on 13/10/2009 with hyperpigmentation and darkening of the skin that had been developed for previous 5 months accompanied by fatigue for a period of more than a year with lumbar back pain. During his physical examination, he had a core body temperature of 36 C , a pulse 84 beats per minute, a respiratory rate 20 breaths per minute and a blood pressure of 100/60 mmHg. He had mild pallor, but no jaundice or cyanosis. Skin showed generalized hyperpigmentation with prominent gingival and buccal mucosa darkening. There was no significant peripheral lymphadenopathy. Thyroid gland was not enlarged. His abdomen was soft and flat with no organomegaly. Chest and cardiac examinations revealed no abnormalities. Laboratory findings included a red blood cell count of 4.51 x 1012/ L; hemoglobin 11.1 g/dl; white blood cell count 16.31 x 109/ L; (neutrophils 61.6%; lymphocytes 13.1%; monocytes, 7.0%; eosinophils, 0.1%; basophils, 0.7%); platelet count 308 x 109/ L; high erythrocyte sedimentation rate (42 mm/h), high C-reactive protein (14.88mg/L), low-serum sodium (129 mmol/L), high-serum potassium (5.4 mmol/L), low serum chloride (92 mmol/L), blood glucose level (118 mg/dl), normal kidney function, normal liver function, low-serum cortisol 8 am (2.9 mug/dL), 4 pm (2.6 mug/dL), TB IgM antibody (-ve), TB IgG antibody (+ve) and positive purified protein derivative test (PPD). A Chest x-ray revealed no abnormalities. A Thoracic lumbar plain film revealed narrowing of the L1- L2 space with irregularity and osteolysis of the endplates suggesting the possibility of lumbar spine TB (Figure 1 - A). An Abdominal CT imaging revealed bilateral adrenal mass like enlargement with irregular enhancement and lesion like changes without calcification (Figure 1 - b-d). Based on the clinical presentation, laboratory findings of positive IgG anti-TB antibodies, positive PPD test, High ESR, low serum cortisol, low sodium level and high potassium level, beside the radiological findings of spinal and adrenal involvement, the diagnosis of combined primary adrenal and spinal TB with adrenal insufficiency was highly suggested.
Based on this diagnosis, the patient started anti-TB drugs in the form of (isoniazid, rifampicin, ethambutol, pyrazinamide) in combination with vitamin B6 tablets and steroid therapy in the form of prednisolone (7.5 mg/day) in two divided dose of 5 mg in the morning 8 am and 2.5 mg afternoon at 4 pm. He was called for clinical follow up every 6 months and all the necessary investigations were performed each time.
In the recent follow up of our patient in 2012, he was without clinical symptoms and all the laboratory investigations were nearly normalized. The anti TB drugs were stopped but steroid therapy in the form of prednisolone is continued with same dose as earlier. The thoracic lumbar plain film taken later in 2012, that we have presented in the article demonstrated nearly the same finding as shown in the earlier film taken during the initial presentation (Figure 1-e). A CT scan of his adrenal glands documented a relevant reduction of the bilateral adrenal masses and the adrenal lesions were significantly reduced than the earlier CT film along with diminished degree of enhancement (Figure 1-f-h), however it is not conclusive about the restoration of its normal adrenal function.