Primary Adrenal Insufficiency due to Cryptococcus With Persistent Adrenal Enlargement and Insufficiency

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Background/Objective Infiltrative fungal infections are an unusual cause of primary adrenal insufficiency (AI). Our objective is to present long term follow-up of a patient with AI due to crytpococcal adrenalitis. Case Report A 47 year old woman presented in January 2004 with a 50 lb. weight loss, nausea, emesis, and headache with diplopia. During the 6 months prior to her presentation the patient had multiple admissions for evaluation of recurrent nausea and emesis. Prior to the most recent of these admissions the patient developed headache; evaluation of her cerebrospinal fluid revealed cryptococcus and she was treated with a two week course of Amphotericin B. Physical examination demonstrated temperature of 101.1 °F, HR 110 bpm, BP 94/65 mmHg, ill appearing underweight woman with dry mucous membranes, and photophobia. Laboratory revealed random cortisol of 0.5 ug/dL. CT imaging showed bilateral adrenal gland enlargement and FNA of adrenal gland revealed encapsulated budding yeast. Stress dose IV glucocorticoids were administered and switched to oral Hydrocortisone and Fludrocortisone as patient clinically improved with second course of Amphotericin B. Further evaluation in 2017 revealed persistently enlarged adrenal glands, positive cryptococcus antigen and low IgG levels. Discussion Our literature review noted few publications of AI caused by disseminated cryptococcus with no long term follow up of these cases beyond a 1-4 year time frame. Conclusion Patients with AI due to disseminated fungal infect warrant long term follow up to assess for resolution of adrenal enlargement and evaluation of immunocompromised status.

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