Adrenal Tuberculosis

Adrenal Tuberculosis – Treatment Options

Introduction
Adrenal tuberculosis (TB) is a form of extrapulmonary tuberculosis that affects the adrenal glands, often leading to destruction of adrenal tissue and subsequent primary adrenal insufficiency (Addison’s disease). It is an important cause of adrenal failure in regions where TB remains prevalent. The onset is usually insidious, with clinical features such as fatigue, weight loss, anorexia, abdominal pain, hyperpigmentation, hypotension, hyponatremia, and hyperkalemia. Diagnosis is supported by imaging (bilateral adrenal enlargement or calcification), endocrine testing (low cortisol with high ACTH), and microbiological confirmation where possible. Management requires both antituberculous therapy to eradicate infection and hormonal replacement for adrenal failure.

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1. Antituberculous Therapy (ATT)

• Standard multidrug TB regimen is administered, following national or WHO guidelines.

  • Isoniazid, rifampicin, pyrazinamide, ethambutol for the intensive phase (usually 2 months).

  • Isoniazid and rifampicin for the continuation phase (typically 4–7 months).

• Total duration of therapy ranges from 6 to 9 months, extended to 12 months in complicated cases.

• Adherence to therapy is essential to prevent drug resistance.

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2. Glucocorticoid Replacement

• Since adrenal destruction is often irreversible, lifelong steroid replacement is usually required.

• Hydrocortisone is the preferred agent.

  • Dose: 15–25 mg/day orally in divided doses (e.g., 10 mg morning, 5 mg afternoon, ± 5 mg evening).

• Prednisolone (3–5 mg/day) may be used as an alternative.

• Dose adjustments are based on symptoms, body weight, and stress conditions.

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3. Mineralocorticoid Replacement

• Fludrocortisone acetate is required in cases of confirmed mineralocorticoid deficiency.

  • Dose: 0.05–0.2 mg/day orally.

• Titration is guided by blood pressure, electrolytes, and plasma renin activity.

• Adequate salt intake is recommended.

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4. Management of Adrenal Crisis

• In patients presenting with acute adrenal crisis due to adrenal TB:

  • Hydrocortisone 100 mg IV bolus, followed by 200 mg/24 hours infusion or 50 mg every 6 hours.

  • IV 0.9% saline for hypovolemia and dextrose if hypoglycemia occurs.

• Once stabilized, transition to long-term oral replacement therapy.

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5. Monitoring and Supportive Care

• Regular monitoring of cortisol, ACTH, electrolytes, blood pressure, and weight.

• Periodic imaging (CT/MRI) to assess adrenal size and detect resolution or calcification.

• Monitoring for TB drug toxicity (hepatic, ocular, neurologic) during therapy.

• Screening for coexisting TB in lungs, kidneys, and other organs.

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6. Patient Education and Prevention

• Patients should be educated about lifelong need for hormonal replacement therapy.

• They must carry a medical alert ID and an emergency hydrocortisone injection kit.

• Education on stress dosing during illness, surgery, or trauma is essential to prevent adrenal crisis.

• Close follow-up ensures adherence to TB treatment and optimization of hormone therapy.