Rifampicin induced adrenal crisis in an uncommon setting
A 46-year-old nondiabetic and nonhypertensive female patient presented initially with complaint of central chest pain for 3 months which was insidious in onset, no particular aggravating and relieving factors. She also had weight loss, anorexia, and fatigue for the same duration. A computed tomography (CT) of thorax showed mediastinal lymphadenopathy with no parenchymal involvement. Transbronchial needle aspiration (TBNA) from the mediastinal lymphnodes revealed granulomatuos inflammation. Bronchial washings’ analysis was negative for acid fast bacilli (AFB) stain and culture. A Mantoux test was strongly positive. Based on these investigations, the patient was started on four drug antitubercular therapy (isoniazid, rifampicin, pyrazinamide, and ethambutol). Ten days after starting of antitubercular therapy, patient presented to the emergency department with complaint of increased chest pain and vomiting. On examination, patient was fully conscious with blood pressure of 70/50 mmHg. Adrenal insufficiency was suspected and serum cortisol was sent which was low. A corticotrophin test showed adequate response indicating secondary adrenal insufficiency due to hypothalamopituitary axis (HPA) failure.[] A CT abdomen done revealed normal adrenals, suggesting involvement of HPA as a cause of adrenal insufficiency. On further enquiry, the patient gave a history of significant postpartum bleeding around 17 years back with difficult lactation in the last childbirth. In the last 2 years she had also noticed gradual loss of axillary and pubic hair and her periods had stopped since last 3 years. Hormone assay revealed low luteinizing hormone (LH), follicle stimulating hormone (FSH), testosterone, thyroid stimulating hormone (TSH) []. Magnetic resonance imaging (MRI) of brain revealed empty sella turcica with nonvisualization of pituitary gland [Figures and ]. A diagnosis of postpartum hypopituitarism (Sheehan syndrome) was made based on the above history and investigation findings. Patient was put on steroids (intravenous hydrocortisone followed by oral prednisolone) to which she responded. The chest pain and vomiting abated and hypotension was reversed. She subsequently recovered completely. Steroids and antitubercular drugs were continued.