Persistence of histoplasma in adrenals 7 years after antifungal therapy
A 50 year old male, a diagnosed case of Addison's disease, presented to the Endocrine clinic of this hospital for reevaluation. His clinical history dated 7 years back when he presented with complaints of hyperpigmentation and weight loss for 10 months. There had been no history of tuberculosis in the past. A diagnosis of primary adrenal insufficiency was made (ACTH 743 pg/ml, post-ACTH cortisol 4.8 mcg/dl, PRA 24.7 ng/ml/h (1.3-3.95) and aldosterone 16.6 ng/dl (4-31) and the patient initiated on glucocorticoids and mineralocorticoids. Both the adrenals were enlarged on CT imaging (rt adrena l6.8 × 3.2 cm and Lt adrenal – 5.8 × 4.0 cm). Adrenal biopsy revealed numerous tiny unstained elliptical yeast-like bodies, some of them showing budding. These were Periodic Acid Schiff stain positive []. He received itraconazol 400 mg daily for 9 months which was then stopped and the patient continued on steroid replacement therapy. Hyperpigmentation, appetite, and weight gradually improved while on therapy. He had developed diabetes for the past 2 years and had been receiving oral hypoglycemics. Present evaluation revealed a 75 kg male with no cutaneous striae; blood pressure was 151/93 mm Hg. Investigations revealed a normal hemogram with ESR-40, and normal liver and kidney function tests and Thyroid Function Tests, ACTH 19.5 pg/ml and post-ACTH cortisol levels 4.3 mcg/dl after 1 day of missing the steroid preparation. HIV serology was negative. A repeat CT imaging revealed bilaterally enlarged adrenals with no significant change in either the size or the morphology of the adrenals when compared to the previous CT imaging. Repeat adrenal biopsy revealed necrotic tissue with numerous spores of histoplasma capsulatum that stained positive with the PAS stain and Grocott methanamine silver stain [].