MON-350 Disseminated Histoplasmosis Manifesting as Adrenal Insufficiency: A Rare Presentation of a Common Infection

Background: Histoplasmosis is a common fungal infection in endemic areas, however it can rarely cause symptomatic disease requiring medical care in some patients. (1) We describe the case of a patient with untreated human immunodeficiency viral (HIV) infection who developed adrenal insufficiency (AI) from disseminated histoplasmosis (DH). Clinical Case: A 56-year-old male with untreated HIV infection and hypertension was evaluated for left upper jaw swelling and pain of 3 months duration. Exam was remarkable for palpable cervical lymph nodes, oral thrush, mass in the posterior maxillary region near the left molars and generalized rash on the upper chest and back. CT chest showed bilateral adrenal gland enlargement measuring 4.1 x 3.6 cm on the left and 2.7 x 2.3 cm on the right with ground glass opacity on the right lower lobe of the lung and hilar lymphadenopathy. MRI brain showed a 3.9 x 5.8 x 4.3 cm soft tissue mass in the posterior aspect of the left maxilla with erosion into maxillary sinus. Biopsy from maxillary mass was positive for histoplasmosis. Laboratory testing showed significant hyponatremia and hyperkalemia. A 250 mcg cosyntropin test was obtained and was consistent with primary AI with an elevated ACTH level of 86 pg/ml (7-69 pg/ml). He was treated with amphotericin for histoplasmosis with good clinical response. He was also started on mineralocorticoid and glucocorticoid replacement for adrenal insufficiency and eventually weaned off mineralocorticoids. Repeat adrenal CT scan 3 years after treatment showed reduction in the size of the adrenal gland however patient continues to be on glucocorticoid replacement for AI. Conclusion: Adrenal involvement is not commonly seen in DH. Even in patients with adrenal involvement, development of adrenal insufficiency in DH is rare.(2) Addison’s disease was reported in 14.3% of patients with adrenal histoplasmosis in one case series (3). Kauffman et al reported only 12 out of 58 elderly patients with histoplasmosis had adrenal involvement and none of them had adrenal insufficiency. Adrenal histoplasmosis though rare, should be considered as a differential in patients presenting with unilateral or bilateral adrenal masses and adrenal insufficiency, especially in endemic areas. Our case demonstrates the importance of being vigilant about this association, since delay in treatment could result in life threatening consequences. References: 1. Kaufman CA. Histoplasmosis: A clinical and laboratory update. Clinical Microbiology Reviews. Volume 20, Issue 1, January 2007, Pages 115-132 2. Wahab NA et al. Adrenal involvement in histoplasmosis. EXCLI Journal. 2013;12:1-4. 3. Larbcharoensub N et al. Adrenal histoplasmosis: A case series and review of the literature. Southeast Asian journal of tropical medicine and public health 2011 42(4):920-5