Indian Journal of Radiology Indian Journal of Radiology  

   Login   | Users online: 593

Home Bookmark this page Print this page Email this page Small font sizeDefault font size Increase font size     

 

HEAD AND NECK Table of Contents   
Year : 2006  |  Volume : 16  |  Issue : 4  |  Page : 651-652
Disseminated histoplasmosis of adrenal gland


Department of Radio-diagnosis, JLN Hospital & Research Centre,Bhilai Steel Plant, Bhilai, Chhattisgarh, India

Click here for correspondence address and email

Date of Submission19-Sep-2005
Date of Acceptance10-Jun-2006
 

Keywords: Disseminated Histoplasmosis, Adrenal, FNAC

How to cite this article:
Dwivedi M K, Piparsania B, Issar P, Dewangan L. Disseminated histoplasmosis of adrenal gland. Indian J Radiol Imaging 2006;16:651-2

How to cite this URL:
Dwivedi M K, Piparsania B, Issar P, Dewangan L. Disseminated histoplasmosis of adrenal gland. Indian J Radiol Imaging [serial online] 2006 [cited 2019 Dec 13];16:651-2. Available from: http://www.ijri.org/text.asp?2006/16/4/651/32291

   Introduction Top


60 year old male patient presented with history of high grade intermittent fever since last two months, not associated with chills & rigor and loss of appetite. He had history of diabetes since past 7 years.


   Materials & Methods Top


Patient was initially investigated by ultrasound then by CT Scan and Lab. Findings were:

- Blood Cell count report is with in normal limit. The work up for malignancy & tuberculosis was negative and patient were seen negative for HIV Virus. Pleural Fluid Aspiration revealed haemorrhagic fluid with lymphocyte count 2000/mm3 (raised). Elevated alkaline phosphatase (244 U/L) and Gamma GT. Patient has A / G reversal. Chest X-Ray: Normal except left sided pleural collection. USG Machine: Siemens - Sonoline prima; 3.5 Hz convex probes. CT Scan: GE/Fx-i Hispeed Spiral CT Machine

This was followed by CT Guided biopsy of adrenal gland.


   Results Top


Abdominal sonography revealed:

- Hepatomegaly (18 cm in midclavicular line) with healed calcified granulomatous lesion in the Rt. lobe of liver. Few enlarged lymphnodes visualized at porta. Lt. sided pleural collection.

Adrenal Gland:

- Measures Approx. Rt.: 3.2 x 2.8 cm and Lt.: 4.9 x 3.5 cm

- Both adrenal gland are enlarged and hypo and triangular in shape.

- Prostate enlarged. [Figure - 1]

CT Scan revealed:

On NECT:

- Massive enlargement of both adrenal glands with focal low attenuating nodules. Fat planes all around the gland were preserved. No calcification seen with in the adrenal gland. No pulmonary lesion noted except left sided pleural collection [Figure - 2]. Contrast enhanced CT revealed heterogeneous enhancement of the both adrenal gland [Figure - 3]

Fine Needle Aspiration Cytology (F N A C):

FNAC was performed under CT guidance from Rt. adrenal gland, which revealed cluster of Macrophages with abundant cytoplasm containing yeast form of histoplasma capsulatum.

Then patient were subjected to Itraconazole (200 mg BD) for 6 month and he responded well.


   Discussion Top


Disseminated Histoplasmosis is a rare and potentially fatal disease caused by diamorphic soil fungus Histoplasma Capsulatum [7]. The clinical manifestation of chronic Disseminated Histoplasmosis in a non-HIV patient resemble those of other chronic infection i.e. Tuberculosis or malignancies [10].

Non-HIV patient usually presents with low grade fever, weight loss, anorexia, night sweats with the features of adrenal insufficiency, especially in the endemic areas [9].

It is more common in Male, Male to female ratio is 3-10:1. In 99% cases infection is subclinical.

Incidence is 2-5% in AIDS patient <0.05% in non-HIV patient. Common age: 1/3rd of these cases are infant < 1 year of age and prevalence increases with the age > 60 years.

On USG: Non-HIV patient usually presents with hepatosplenomegally and bilateral adrenal enlargement [1]. Adrenal Masses are usually hypoechoic and can be homogenous or hetrogenous in texture [1]. Most characteristic feature is maintenance of triangular shape [4].

Abdominal CT Finding includes: Hepato-splenomegaly, Diffuse splenic hypoattenuation Bilateral adrenal enlargement or hypoattenuating masses. Enlarged lymph nodes with homogenous soft tissue density, diffuse or central low density or both [2].

Adrenal Gland: The range of adrenal gland findings on CT includes minimal enlargement with faint flecks of calcium, moderate enlargement with focal low attenuation nodules and massive enlargement with large areas of necrosis or calcification [3]. These changes are usually bilateral and symmetrical [3] and shape of adrenal gland is usually preserved [3].

Post contrast studies shows variable enhancement, which can be hetrogenous or homogenous [1].

FNA Biopsy of the adrenal gland revealed cluster of macrophages with abundant cytoplasm containing yeast form of histoplasm capsulatum [8]. Differential diagnosis of adrenal masses on CT includes tuberculosis, adenoma, metastasis, Primary carcinoma, pheochromocytoma and post inflammatory lesions [5].

FNAB of adrenal gland in an effective method in the diagnosis of unusual infectious diseases [6].


   Conclusion Top


Bilateral adrenal enlargement in a non-immunocompramised and non-tubercular patient with variable clinical presentation should always raised the suspicion of histoplasmosis and which subsequently should be confirmed by FNAC.

 
   References Top

1.Kumar M, Singh S, Govil S. Adrenal Histoplasmosis: Clinical presentation and imaging features in 9 cases. Abdominal Imaging, 2003, Sept-Oct.; 28(5); 703 - 708.  Back to cited text no. 1    
2.Dr Radin. Disseminated histoplasmosis: abdominal CT findings in 16 patients. AJR 1991, Vol. - 157; 955 - 958.  Back to cited text no. 2    
3.Wilson DA, Muchniore HG, Tisdal RG, Fahmy A, Aitha JV. Histoplasmosis of adrenal gland studied by CT. Radiology 1984, March; 150 (3); 779 - 783.  Back to cited text no. 3    
4.Wilson DA, Mynyen DL, Tylk TL, Swancy CM, Muchmore HG. Sonography of adrenal glands in chronic disseminated histoplasmosis. J Ultrasound Med. 1986, Feb.; 5 (2), 69 - 73.  Back to cited text no. 4    
5.Luning M, Hoppe E, Schopke W. Results of diagnosis of adrenal masses using percutaneous CT guided fine needle biopsy. Rofo 1986, Feb.; 144 (2); 154 - 159.  Back to cited text no. 5    
6.Deodhare S, Sapp M. Adrenal histoplasmosis: diagnosed by fine needle aspiration biopsy. Diagn. Cytopathol., 1997, July; 17 (1); 42 - 44.  Back to cited text no. 6    
7.Schonfeld AD, Jackson JA, Smith DJ, Hurley DL. Disseminated histoplasmosis with bilateral adrenal enlargement: diagnosis by camputed tomography - direct needle biopsy. Tex Medicine 1991, April; 87(4); 88 - 90  Back to cited text no. 7    
8.Anderson CJ, Pitts WC, Weises LM. Disseminated histoplasmosis diagnosed by fine needle aspiration biopsy of the adrenal gland - A case report. Acta Cytol, 1989, May - June; 33 (3), 337 - 340.  Back to cited text no. 8    
9.Levine E. CT Evaluation of active adrenal histoplasmosis. Urol. Radiology, 1991; 13 (2); 103 - 106.  Back to cited text no. 9    
10.Grover SB, Midha N, Gupta M, Sharma V, Talib V H. Imaging spectrum in disseminated histoplasmosis - case report and brief review. Australas Radiology, 2005, April; 49 (2); 175 - 178.  Back to cited text no. 10    

Top
Correspondence Address:
M K Dwivedi
Qr.No. 1/A, Street 05,Sector - 9, Bhilai (Chhattisgarh)
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-3026.32291

Rights and Permissions


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3]

This article has been cited by
1 Disseminated histoplasmosis in an apparently immunocompetent individual from north India: a case report and review
Sushruta Kathuria,Malini Rajinder Capoor,Sachin Yadav,Avninder Singh,V. Ramesh
Medical Mycology. 2013; 51(7): 774
[Pubmed] | [DOI]
2 Adrenal histoplasmosis: A diagnosis on fine needle aspiration cytology
Rana, C. and Kumari, N. and Krishnani, N.
Diagnostic Cytopathology. 2011; 39(6): 438-442
[Pubmed]
3 Adrenal histoplasmosis: A diagnosis on fine needle aspiration cytology
Chanchal Rana,Niraj Kumari,Narendra Krishnani
Diagnostic Cytopathology. 2011; 39(6): 438
[Pubmed] | [DOI]
4 Bilateral adrenal histoplasmosis in immunocompetent patients
Chanchal Rana, Narendra Krishnani, Niraj Kumari
Diagnostic Cytopathology. 2011; 39(4): 294
[VIEW] | [DOI]
5 [18F]Fluorodeoxyglucose-avid adrenal masses due to histoplasmosis
Shah, S.A., Rangarajan, V., Purandare, N.C., Arora, A.J., Sharma, A.R., Viswanathan, S.
Journal of Clinical Oncology. 2009; 27(5): 827-828
[Pubmed]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  


    Introduction
    Materials & Methods
    Results
    Discussion
    Conclusion
    References
    Article Figures

 Article Access Statistics
    Viewed4002    
    Printed94    
    Emailed1    
    PDF Downloaded339    
    Comments [Add]    
    Cited by others 5    

Recommend this journal