(583) Emergence of Adrenal Insufficiency After Treatment of Miliary Tuberculosis

Introduction: Miliary tuberculosis (TB) is a challenging entity to diagnose and treat. In immunosuppressed hosts, latent TB can reactivate to miliary TB, leading to lymphohematogenous spread of Mycobacterium tuberculosis affecting multiple organ systems. Primary adrenal insufficiency in TB infection is a known rare complication; however, adrenal crisis associated with TB treatment is less well described.

Description: A 64-year-old Filipino female with a history of allograft kidney transplant in 1989 and isoniazid-treated latent TB infection was admitted for symptomatic hyponatremia associated with poor oral intake. Her hyponatremia was initially attributed to hypovolemia and treated as such; however, on hospital day three, the patient developed tachycardia, hypotension and worsening hyponatremia, and so stress dose steroids were initiated due to concern for adrenal insufficiency. The patient’s vitals and sodium corrected while on a hydrocortisone taper, but on hospital day eight, she developed altered mental status and SIRS criteria concerning for sepsis. CT imaging showed findings concerning for miliary TB, and diagnosis was confirmed by nucleic acid amplification testing on bronchoalveolar lavage fluid. Anti-tuberculosis antibiotic therapy plus dexamethasone for neurological involvement was initiated on hospital day twelve, but she later developed recurrent hyponatremia, distributive shock and renal failure requiring vasopressor support and continuous renal replacement therapy. Given concern for adrenal insufficiency secondary to miliary TB and its treatment with rifampin, fludrocortisone was added to dexamethasone to meet both mineralocorticoid and glucocorticoid needs. The patient was able to come off vasopressor support within eight hours of initiation of stress dose steroids.

Discussion: Adrenal insufficiency in miliary TB can occur at any point in its clinical course. Interestingly as well is that through rifampin’s pharmacokinetics, it can also induce an adrenal insufficiency in this patient population. This case highlights the importance of appropriate hormonal replacement therapy when treating adrenal insufficiency in patients with miliary TB and emphasizes the need for awareness of this complication.