Radiology Page

Adrenal Tuberculosis
A 54-year-old female immigrant from Southeast
Asia presented with a 5-week history of fatigue,
fever, cough, headaches, left numbness and a remote
history of pulmonary nodules. Contrast enhanced
abdominal computerized tomography (CT) showed a
4 cm right adrenal mass with multiple central areas
of low density and peripheral enhancement (fig. 1), a
normal left adrenal gland and thickening of the wall
of the distal ileum. The chest CT revealed multiple
small, centrilobular pulmonary nodules and scattered areas of irregular consolidation (fig. 2). Magnetic resonance imaging (MRI) of the brain demonstrated multiple rim enhancing lesions in both
cerebral hemispheres.
Active tuberculosis (TB) was considered the most
likely diagnosis given the clinical and imaging findings and was confirmed on bronchoscopy. Laboratory results, including normal morning cortisol with
adequate response to acetylcysteine hormone (ACTH)
stimulation, excluded Addison disease. The patient
was started on a 4-drug tuberculosis therapy. Followup imaging demonstrated persistent enlargement of the right adrenal gland with clearing of the
central cystic areas, resolution of the ileal mural

Figure 1. Contrast enhanced axial CT image of abdomen shows

right adrenal gland mass with central areas of low density and
peripheral enhancement. Left adrenal gland appears normal.

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Figure 2. Contrast enhanced axial CT image of chest reveals

multiple small, centrilobular nodules throughout both upper
lobes and irregular consolidation in right upper lobe.

thickening, improved pulmonary findings and decrease in size of brain abscesses.

The prevalence of TB has continued to decline in
the United States but the prevalence has increased
globally.1 While TB is usually confined to the respiratory system clinically, any organ system can be
involved. Adrenal TB is seen in 6% of patients with
active tuberculosis, and the adrenal gland is the fifth
most common site of extra pulmonary tuberculosis
following the liver, spleen, kidney and bone.2
While autoimmune adrenalitis has surpassed TB
as the most common cause of Addison disease, adrenal TB remains a major cause of the disease in
developing countries.3 Clinical manifestations of Addison disease are seen in 12% of patients with adrenal TB2 and occur when 90% of the adrenal tissue is
destroyed by the infection.3 Associated symptoms
are commonly nonspecific, including fatigue, weakness, anorexia, dizziness, nausea and vomiting.4
Physical examination may reveal cutaneous or mucosal hyperpigmentation, weight loss and orthostatic hypotension. Routine laboratory findings include hyponatremia, hypoglycemia, mild normocytic
anemia, lymphocytosis and eosinophilia.4 Specific
laboratory tests for suspected Addison disease inVol. 187, 285-286, January 2012
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clude basal cortisol levels, plasma ACTH and rapid

ACTH stimulation tests. Although acute adrenal insufficiency due to adrenal TB is rare, it should not be
missed because of the possibility of adrenal crisis, a
potentially life threatening disorder during physiological distress.
Specific imaging features, including location, contour and presence of calcifications, can be used in
combination with clinical signs and symptoms to
help differentiate between tuberculosis and other
lesions of the adrenal glands.5 Bilateral adrenal involvement has been documented in 69% to 91% of
adrenal tuberculosis cases.2,5,6 Primary adrenal tumors typically present unilaterally. Pheochromocytoma is the most common primary adrenal tumor to
present bilaterally with a rate of 10%.6 Metastases
may be bilateral but are usually seen in patients
with known primary malignancy. Destruction of adrenal glands progressively alters the contour of the
gland. Early in the disease process when caseous
necrosis and granuloma formation commence there
is mass-like enlargement (59% of cases) of the adrenal or diffuse enlargement (41%) with preservation
of the contours of the adrenal gland.5 Later stages of
disease are manifested by atrophied adrenal glands
with fibrosis and calcifications. Calcifications are
seen in 59% of adrenal TB cases but in only 8% of
adrenal tumors.5 Adrenal tuberculosis commonly
presents with a low attenuation center and peripheral enhancement on CT, a finding seen in 47% of
patients with TB but in only 9% of primary adrenal
tumors.5 This pattern is attributed to fibrous tissue
and granulomatous inflammatory tissue surrounding the area of central necrosis.
Common MRI findings in adrenal tuberculosis
include bilateral involvement, T2-weighted imaging,

hypointense or isointense signal of the central region and peripheral rim enhancement.6 MRI is particularly useful in patients with known allergies to
iodine contrast material but it is not as good as CT in
demonstrating calcifications. Ultrasound findings
are nonspecific and usually consist of a soft tissue
mass, perhaps with calcifications. Biopsy might be
necessary to differentiate adrenal TB from an adrenal neoplasm or other infectious process.
It is imperative that radiologists and clinicians
understand the typical clinical and imaging features
of adrenal tuberculosis. The presence of extra adrenal involvement, as in this case, may strongly suggest the diagnosis but it is not diagnostic by itself.
Prompt diagnosis is usually achieved by a combination of clinical, laboratory, imaging and pathological
findings, and is necessary to implement appropriate
treatment and minimize patient morbidity.
Kevin Day, Paul Nikolaidis and David D. Casalino
Department of Radiology
Northwestern University, Feinberg School of Medicine
Chicago, Illinois
1. Burrill J, Williams CJ, Bain G et al: Tuberculosis: a radiologic review. Radiographics 2007; 27: 1255.
2. Lam KY and Lo CY: A critical examination of adrenal tuberculosis and a 28-year
autopsy experience of active tuberculosis. Clin Endocrinol 2001; 54: 633.
3. Guo YK, Yang ZG, Li Y et al: Uncommon adrenal masses: CT and MRI features
with histopathologic correlation. Eur J Radiol 2007; 62: 359.
4. Oelkers W: Adrenal insufficiency. N Engl J Med 1996; 335: 1206.
5. Yang ZG, Guo YK, Li Y et al: Differentiation between tuberculosis and primary
tumors in the adrenal gland: evaluation with contrast-enhanced CT. Eur Radiol
2006; 16: 2031.
6. Zhang XC, Yang ZG, Li Y et al: Addisons disease due to adrenal tuberculosis:
MRI features. Abdom Imaging 2008; 33: 689.