Primary adrenal tuberculosis infection in patients with Behcet’s disease presenting as isolated adrenal metastasis by ¹⁸F-FDG PET/CT: a rare case report and literature review

Introduction

Adrenal TB, the fifth most common cause of EPTB after tuberculosis of the liver, spleen, kidney and bone (1), is rare and represents between 1–2% of the etiologies of adrenal masses (2), and it can be isolated or coexist with pulmonary tuberculosis (PTB). Adrenal involvement was discovered in 6% of the autopsy series of patients with active tuberculosis (1). Adrenal TB is an essential etiology of Addison’s disease, especially in developing countries (3). However, Addison’s disease does not appear until more than 90% of the gland is destroyed (4). Furthermore, adrenal TB patients generally have a history of PTB, but nearly 12% of adrenal TB patients may have no extra-adrenal TB (5).

In recent years, advances in the diagnosis of tuberculosis have been seen with the development of bacterial product detection and imaging evidence. The main diagnostic tests for tuberculosis are sputum smear microscopy, rapid molecular tests, and culture-dependent methods. The molecular testing of the Xpert MTB/RIF assay (Cepheid, Sunnyvale, CA, USA) recommended by WHO can simultaneously detect tuberculosis (better accuracy than smear microscopy) and drug resistance (rifampicin). Culture-based methods are the accepted reference standard, but these take much more intricate lab capacity and require up to 3 months to obtain the results. In addition, the urinary lipoarabinomannan (LAM) test is presently recommended for seriously ill and hospitalized patients with human immunodeficiency virus (HIV) and CD4 ≤100 cells per µL. Chest X-ray is now endorsed by WHO for screening and diagnosing tuberculosis in some populations (6).

Adrenal TB is characterized by a distinctive clinical and radiological pattern, and it is challenging to obtain an accurate diagnosis even after biopsy. The clinical symptoms of adrenal TB are atypical and include adrenal incidentaloma and adrenal insufficiency with a unilateral or bilateral mass-like enlargement of adrenal glands (7). The imaging examinations usually lack specificity. The CT scans reveal enlarged adrenal glands when Mycobacterium tuberculosis invades, leading to misdiagnosis of a primary adrenal tumor or an adrenal metastasis from other organs. Consequently, a single detection method has difficulty distinguishing adrenal TB from malignant metastatic lesions. The complexity of the acquisition of puncture samples also leads to the difficulty of making accurate diagnoses. A histological examination of the specimens is the gold standard for diagnosis. Therefore, it is difficult to diagnose adrenal TB in routine TB-related examinations. As primary adrenal TB is a rare clinical entity, we describe a rare case of primary adrenal TB with a review of the literature on this subject. We present the following case in accordance with the CARE reporting checklist (available at https://dx.doi.org/10.21037/gs-21-511).

Case presentation

A 59-year-old man was admitted for recurrence of oral (≥0.5 cm) and genital aphthosis (≤0.5 cm) for 3 years, which could not be effectively controlled by irregular medication usage. The patient presented with no family history of adrenal cancer, other malignancy, other endocrinopathy or tuberculosis. Additionally, he had never been vaccinated against tuberculosis and did not come from a tuberculosis endemic region. Chest computed tomography (CT) scan showed multiple small nodules and interstitial changes in both lungs, and enlarged adrenal gland (Figure 1A). The result of sputum cultures for tuberculosis was negative. Based on symptoms of oral and genital aphthosis, the patient was diagnosed with Behcet’s disease according to the International Criteria for Behcet’s disease (8). The laboratory examinations were as follows: the erythrocyte sedimentation rate (ESR) was 20.00 mm/h (normal range: 0–15 mm/h), and the antinuclear antibody (ANA) was positive. The tumor markers [carcinoembryonic antigen (CEA), alpha fetoprotein (AFP), cancer antigen 125 (CA125), carbohydrate antigens], rheumatoid factor, adrenal and pancreatic biochemical evaluations (cortisol, supine and standing aldosterone, serum sodium and potassium, pancreatic amylase and lipase), HLA-B27/HLA-B7 and extractable nuclear antigen (ENA) antibodies were in the normal reference ranges. Then, he was given thalidomide (0.50 g/day, orally) as well as Kangfuxin liquid (10 mL three times a day, orally) to promote aphthosis healing.

Figure 1 The dynamic changes in adrenal CT images of the patient in our case during hospitalization. (A) Adrenal CT on the first day after admission revealed a right adrenal mass with a size of 2.0 cm ×2.0 cm ×0.9 cm. (B) Adrenal contrast-enhanced CT on the fifth day after admission showed a right adrenal mass with a size of 2.0 cm ×2.1 cm ×0.9 cm that exhibited peripheral rim enhancement. (C) Adrenal CT revealed that the size of the adrenal mass increased to 2.5 cm ×2.3 cm ×1.0 cm on the 17th day after admission. (D) Adrenal contrast-enhanced CT showed an adrenal mass with an increased size of 3.1 cm ×2.5 cm ×1.5 cm on the 24th day after admission. The adrenal mass is indicated by a thick arrow.

After 10 days of admission, the patient had sudden abdominal pain in the right upper quadrant with a fever of 38.6 °C. Abdominal CT revealed gallstones with a maximum diameter of 0.8 cm, indicating an acute cholecystitis attack. After antibiotic and symptomatic supportive treatment for 3 days, the patient still had intermittent right upper abdominal pain and high fever. As careful preoperative evaluation of the patient’s current general state was performed by anesthesiologists, the risk of complications arising from cholecystectomy was particularly high; therefore, the patient underwent percutaneous transhepatic gallbladder drainage (PTGBD), and his pain relief was significant. However, intermittent fever (up to 39.2 °C) was still present. Blood and bile culture results revealed no pathogenic agents. Further adrenal contrast-enhanced CT showed a right adrenal mass and multiple enlarged retroperitoneal lymph nodes, which exhibited peripheral rim enhancement without calcification (Figure 1B) and indicated that a metastatic adrenal mass was suspected. The dynamic variations in adrenal CT images during hospitalization were present in Figure 1A-1D. PET-CT showed intense ¹⁸F-FDG uptake in the right adrenal mass with an SUV_max of 15.2 and foci of intense uptake in the spleen and retroperitoneal lymph nodes (Figure 2). Reconstructed three-dimensional images were presented in Figure 3. A bone marrow puncture only detected leukocytosis without malignant tumor cells.

Figure 2 ¹⁸F-FDG PET/CT of the patient in our case. (A) Maximum intensity projection (MIP) images revealing intensely avid foci in the right suprarenal region (thick arrow) and foci of intense uptake in the spleen (dashed arrows) and retroperitoneal regions (curved arrows). (B-E) CT images showed intense FDG uptake in the right adrenal mass (2.3 cm ×1.8 cm ×1.0 cm) (thick arrow), retroperitoneal lymph nodes (≤2.5 cm ×1.2 cm) (curved arrows) and spleen (0.8 cm ×0.5 cm) (dashed arrows).

Figure 3 Reconstructed three-dimensional images. (A) The right adrenal mass (thick arrow) with a size of 3.1 cm ×2.5 cm ×1.5 cm. (B) The enlarged retroperitoneal lymph nodes were close to the abdominal aorta and inferior vena cava.

Next, regarding the treatment of the right adrenal mass, considering that percutaneous biopsy might cause the risk of tumor metastasis or dissemination and that the limited number of puncture samples or needles could lead to false-positive or false-negative results, the patient underwent retroperitoneal laparoscopic adrenalectomy. During the operation, enlargement of the right adrenal gland was observed. The fat around the kidney was obviously saponified, and the adhesion of the adrenal mass to the surrounding tissues was severe. The excised mass was 2.2 cm ×2.0 cm ×1.5 cm in size with a medium texture. Intraoperative frozen pathological results showed a higher possibility of tissue-derived inflammatory diseases than the possibility of tumorous diseases. Then, we assessed whether to perform lymph node dissection for the patient. We observed the enlarged retroperitoneal lymph nodes were close to the abdominal aorta, and serious adhesion between the lymph nodes and abdominal aorta was present (Figure 3). Considering the unstable general condition, high risk of bleeding and rupture of the abdominal aorta, increased operation time due to surgical separation of adhesive lymph nodes and the result of intraoperative frozen section analysis, regional lymphadenectomy was not performed after communication with the patient’s family. Histological examination of the specimen revealed primary adrenal TB with a granulomatous lesion containing multinucleated giant cells and inflammatory cells with caseous necrosis. Immunohistochemistry showed CD2 (+), CD3 (+), CD20 (+), CD30 (+), CD163 (+), TIA1 (+), Ki-67 (+), Granzyme (+), CD21 (no FDC network) and CD56 (−). The Epstein-Barr virus-encoded RNA (EBER) test was negative (Figure S1). When given levofloxacin solution (levoflox 500 mg/250 mL, once daily, intravenously) and anti-tuberculosis treatment with isoniazid (0.3 g/day, orally), rifampin (0.45 g/day, orally), pyrazinamide (0.75 g twice a day, orally) and ethambutol tablets (0.75 g/day, orally), the patient’s fever symptom was significantly relieved. He accepted postoperative anti-TB medication for six months. At the 1-year follow-up, no abnormal lumps or abscess recurrence were detected by radiographic examination. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

Risk factors for EPTB

Although tuberculosis is often confined to the respiratory system clinically, extrapulmonary dissemination occurs in approximately 15–20% of cases and can lead to devastating clinical consequences (9). EPTB is often misdiagnosed as the clinical symptoms may be obscure and afflict organs at distance from the primary infected site (10). The risk factors for EPTB are receiving increasing attention from researchers and currently include the following broad areas: (I) patient baseline information, including sex and age, may influence the increased risk of developing EPTB. In Morocco, Sbayi et al. analyzed 2,962 EPTB cases from 2000 to 2012 and found males and young populations between 15 and 34 years of age were more likely to be associated with EPTB (11). In the meantime, in Lebanon, O’Son et al. conducted a logistic regression model based on 507 EPTB cases and identified risk factors for EPTB, including female sex and age between 5 and 15 years old (12). In China, a large-scale multicenter observational study found female patients were less inclined to be at higher risk of concurrent PTB, and the risk of concurrent PTB declined with aging (13). (II) The patient’s underlying comorbidities may lead to reduced immune function and an increased incidence of EPTB. Chiu et al. evaluated the association between polycystic kidney disease (PKD) and EPTB in a nationwide population-based cohort study of 13,540 participants. They proposed the PKD cohort demonstrated a significantly higher risk of EPTB than the non-PKD cohort, and medical professionals should preserve a suspicion of EPTB for PKD patients (14). A previous study focused on people living with HIV in Addis Ababa, Ethiopia. Alemu et al. conducted a retrospective study of 566 HIV-positive individuals to investigate the predictors of EPTB. They suggested HIV WHO stage III/IV, CD4 count<50 cells/µL and hemoglobin <10 mg/dL were independent risk factors (15). (III) Some micronutrient deficiencies may be closely linked to the development of EPTB. As vitamin D plays a role in the regulation of immune function by enhancing the antimicrobial activity of monocytes and macrophages, Hammami et al. found vitamin D levels were significantly lower in the EPTB group than in the control group, and vitamin D deficiency was an independent predictor of EPTB (16).

Association between TB and Bechet’s disease

BD is a rare systemic vasculitis with unknown etiology and is characterized by recurrent attacks of oral aphthous ulcers, genital ulcers, ocular lesions and skin lesions (8). The molecular or genetic relationship between TB and BD has attracted the attention of researchers. Efthimiou et al. reported cases of PTB in patients with BD were HLA-B5-positive, which may be a common genetic predisposition. Moreover, BD may be associated with the deficiency of cell-mediated immunity, which contributes to the increased susceptibility to TB (17). Heat shock protein 65 (HSP65) antigens are derived from Mycobacterium, have high homology with HSP60 antigens and are overexpressed in recurrent oral ulcerations, papulopustules and the epidermal areas of erythema nodosum in BD (18), which participates in the molecular biological link between BD and TB. From the perspective of clinical presentation, Mendes et al. proposed “pseudo-BD” can mimic “pure-BD”, presenting with hypersensitivity reactions with M. tuberculosis, including reactive arthritis, erythema nodosum and orogenital ulcers (19). To differentially diagnose “pseudo-BD” related to TB and “pure-BD” without TB, one is to judge whether BD-related symptoms had a complete response after anti-TB therapy (20). In our case, the patient’s BD-related symptoms, including oral and genital lesions, were significantly relieved without recurrence. After the postoperative administration of anti-TB medication for 6 months, the occurrence of “pseudo-BD” may be associated with the pathological effects of TB in the patient. Another method of identification is based on the interferon-γ release assay (IGRA), which may help assess the probability of TB in BD patients (21). After analyzing 173 pure BD patients and 59 BD patients with TB infection, the sensitivity and specificity of IGRA were 88.9% and 74.8%, respectively, and the optimal cutoff for diagnosing active TB was 70/106 spot-forming cells, which improved the diagnostic efficiency of BD patients with active TB (22).

How to discriminate between adrenal TB and other adrenal space-occupying lesions

There are discrepancies between adrenal TB and other adrenal space-occupying lesions in the evolution of disease. At the early stage of TB infection, contrast-enhanced CT imaging reveal enlarged adrenal glands with central necrotic hypodense areas and peripheral enhanced rims. At the late stage, the adrenal gland is atrophied with irregular margins and calcification of the lesion (23). The dynamic changes in adrenal CT images of our patient during hospitalization revealed no calcification or adrenal gland atrophy (Figure 1A-1D). The patient also did not have adrenal insufficiency, which usually occurs when 90% of the gland tissue is destroyed at the late stage of the infection. Therefore, we inferred the patient in our case was at the early phase of adrenal TB infection based on the radiomics signatures. The relevant radiological features among the adrenal infection lesions, malignant adrenal masses and benign adrenal masses are summarized in Table 1. The adrenal gland is a common site for metastases of malignant tumors due to its sufficient blood supply. In general, adrenal TB usually involves both adrenal glands, but the possibility of unilateral involvement cannot be ruled out. In addition, a large, heterogeneous and poorly defined mass with irregular peripheral enhancement can be manifested on contrasted-enhanced CT (71). Calcification and hemorrhagic areas can also sometimes be observed. Unlike the variable contour of TB, most of the primary adrenal tumors appeared as masses or nodules. Both adrenal TB and adrenal metastases can cause gradual destruction of the gland. When 90% of the tissue is destroyed, adrenal cortical dysfunction occurs, which is characterized by Addison’s disease (4). However, the primary adrenal tumor can lead to adrenal hyperfunction instead of adrenocortical insufficiency. A study found less than 10% of adrenal tumors showed calcification (72), but adrenal TB with calcification was seen more frequently (73).

How to discriminate between primary and secondary adrenal TB

Secondary adrenal TB usually occurs bilaterally, and some studies found adrenal calcification is the main imaging feature of secondary adrenal TB (74). Morgan et al. reported adrenal TB, secondary to PTB, had bilateral adrenal calcification, while renal computed tomography showed bilateral adrenal mass-like enlargement (75). The main reason is that the hematogenous or lymphoid transmission of Mycobacterium tuberculosis infection has the same effect on both adrenal glands (74). After searching the relevant electronic literature, primary adrenal TB may be suspected of being diagnosed when it has the following characteristics (3,76): (I) the clinical presentation includes fever, chills, night sweats and weight loss, (II) the laboratory findings include positive IgG anti-TB antibodies, positive purified protein derivative (PPD) test and high ESR, (III) the radiological results of adrenal involvement include CT, MRI and PET-CT, (IV) no other imaging or clinical signs of extra-adrenal TB are observed, and (V) the patient has no prior or current history of tuberculosis. If adrenal TB was not isolated occurrence in any part of the body or if the patient had adrenal TB secondary to primary tuberculosis in the respiratory system, digestive system, urinary system, etc., secondary adrenal TB was highly suspected. Furthermore, characteristics of reported cases of primary adrenal TB were summarized in Table 2.

Conclusions

Primary unilateral adrenal TB without adrenal insufficiency is a rare type of EPTB. ¹⁸FDG PET/CT scans have limitations in differentiating rare metastatic tumors and TB. Due to the relatively low diagnostic efficiency of sputum smear microscopy, rapid molecular tests, culture-based methods and imaging approaches, adrenalectomy or percutaneous biopsy may be required for the diagnosis of adrenal TB, especially without evidence of extra-adrenal disease.

Acknowledgments

The authors would like to acknowledge Three-dimensional visualization technology, YORKTAL.

Funding: The present study was supported by grants from the National Natural Science Foundation of China (grant No. 31800787), the Natural Science Foundation of Liaoning Province (grant No. LQ2017025), the Doctoral Research Startup Foundation of Liaoning Province (grant No. 20180540020), the Medical Scientific Research Project of Dalian City (grant No. 1812038) and the United Fund of the Second Hospital of Dalian Medical University and Dalian Institute of Chemical Physics, Chinese Academy of Sciences (UF-QN-202004).

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://dx.doi.org/10.21037/gs-21-511

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://dx.doi.org/10.21037/gs-21-511). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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