A Second Look

Adrenal insufficiency secondary to biopsy-proven histoplasmosis.A second look

The most popular Case in Point (CIP) submission of February 2013, as chosen by CIP users, was “Adrenal Insufficiency Secondary to Biopsy-Proven Histoplasmosis.” February’s reader favorite explores the case of a 38-year-old man who presented with nausea, vomiting, and weight loss.

Users appreciated the case’s “excellent presentation and discussion” and the well-executed merging of medicine and radiology. The ACR Bulletin spoke with Pavan Kavali, MD, resident at Emory University School of Medicine in Atlanta, Ga., about adrenal insufficiency and CIP submission.

Q: Why did you select “Adrenal Insufficiency Secondary to Biopsy- Proven Histoplasmosis” for submission to CIP?

A: This was such a unique and exciting case that we wanted to share it with readers at all levels of training. Instead of submitting this case to a conference with a limited local audience, we thought it would be of greater benefit to share it via CIP, with its 5,000+ subscriber base. We wanted to encourage readers to come up with a broad differential and then use the clinical information and subtle imaging features to draw the correct diagnosis. When the case was accepted, we knew it would be very well received by the CIP community.

Q: How will this case change the way others practice?

A: Recognizing a life-threatening disease and making a prompt and accurate diagnosis is essential to ensure proper patient care. Our case illustrates not only the need to identify adrenal insufficiency on imaging but also the need for an expeditious biopsy of the adrenal glands in order to confirm suspicion of histoplasmosis.

Q: What is the single most important concept for readers to remember about your case?

A: Addison’s disease secondary to histoplasmosis is usually fatal if left untreated. An adrenal gland biopsy may be helpful in determining the underlying etiology of the adrenal insufficiency.

Q: Disseminated histoplasmosis resulting in adrenal insufficiency and Addison’s disease is a rare diagnosis. To the best of your knowledge, is this condition becoming more commonly seen today as compared to 25 years ago?

A: Advances in imaging sciences have enabled us to identify unique disorders at a higher rate. CT imaging has become commonplace to identify etiology of abdominal pain in the United States. Although the incidence of disseminated histoplasmosis remains similar, we suspect the diagnosis of this entity has become more common due to increasing numbers of imaging studies.

Q: What is the role of MRI in evaluating this diagnosis?

A: MRI may be performed to resolve a diagnostic dilemma. The use of MRI has been reported in cases that involve suspicion of subacute adrenal hemorrhage, possible metastatic disease, or primary adrenal cortical carcinoma.1 With classic findings of peripheral rim enhancement with central hypoattenuation on CT, an MRI may not be necessary.

Q: In developing countries, idiopathic autoimmune disorders are thought to be the leading cause of this condition. What do readers need to know about this group of relatively nondescript disorders?

A: Clinical information is always a necessary component of diagnostic imaging. In the absence of history of infection or immunocompromise, one must always be mindful of the patient’s underlying conditions, including autoimmune causes that would help explain the clinical presentation. Autoimmune adrenalitis is the most common cause of Addison’s disease in the industrialized world, and tuberculosis is the most common cause in developing nations.

Q: Why should radiologists take advantage of CIP?

A: It’s amazing to see the vast variety of cases that are presented on CIP. I have learned so much over the last few years in residency from my peers as well as from some of the foremost pioneers in their fields by going through CIP on a regular basis.

This case was published on February 5, 2013. To view the full case, visit http://bit.ly/JanSecLook.

Submitted by Pavan Kavali, MD and Ronald Mixon, MD.

By Anastasia Simkanin and Michael Opatowsky, MD

Anastasia Simkanin (This email address is being protected from spambots. You need JavaScript enabled to view it.) is the CIP manager for the ACR Education Department. Michael Opatowsky, MD, is an associate editor for CIP.

1. Elsayes KM, et al. “Adrenal Masses: MR Imaging Features with Pathologic Correlation.” Radiographics 2004;24(Suppl 1):S73–86.

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