Bilateral adrenal tuberculosis diagnosed by endoscopic ultrasound-guided fine-needle aspiration cytology.

A 35-year-old patient presented with a 1-month history of fever, fatigue, and loss of weight and appetite. Clinical examination was unremarkable except for hypotension (90/60mmHg). The cause of fever could not be ascertained from routine investigations. Biochemistry results were: serum albumin 2.8gm/dL, international normalized ratio 1.4, serum cortisol 4μg/dL, serum sodium 122mEq/L, and serum potassium 5.8mEq/L. A contrast-enhanced abdominal computed tomography (CT) scan showed bilateral adrenal enlargement. Positron emission tomography (PET)-CT showed uptake only in the adrenal glands on both sides (●" Fig.1). Endoscopic ultrasound (EUS) showed a 5×4cm well-defined, hypoechoic, left adrenal mass, with a definite outline (●" Fig.2a). The right adrenal gland showed a 4×3cm mass (●" Fig.2b). EUS-guided fine-needle aspiration (FNA) was performed on the left adrenal gland (●" Video1). Cytology revealed numerous acid-fast bacilli against a necrotic background (●" Fig.3). A diagnosis of adrenal insufficiency secondary to tuberculosis was made, and treatment with corticosteroids for adrenal insufficiency and antitubercular therapy was started. Patient symptoms showed improvement within 2weeks. Differential diagnosis of bilateral enlarged adrenal glands includes infections such as tuberculosis, histoplasmosis, neoplastic masses (malignant metastases, adrenal carcinoma, pheochromocytoma, lymphoma), and autoimmune disease (Addison’s disease) [1,2]. Tissue diagnosis can be undertaken by ultrasound, CT or EUSguided FNA of adrenal glands. Various approaches have been used for ultrasound and CT-guided adrenal sampling. Complications occur in 2.8%–8.4% of cases and include adrenal hematoma, pneumothorax, perinephric hemorrhage, pain, Fig.2 Endoscopic ultrasound images. a Left adrenal mass. b Right adrenal mass.