Adrenal Tuberculosis in Children

Key Points

• Major cause of primary adrenal insufficiency in developing countries
• Bilateral adrenal involvement in 90% cases
• Can cause Addison's disease
• Often diagnosed late due to non-specific symptoms
• Requires long-term endocrine follow-up

Pathophysiology

• Disease Mechanism:
  • Hematogenous spread from primary focus
  • Granulomatous inflammation of adrenal tissue
  • Progressive destruction of adrenal cortex
  • Fibro-calcific changes in advanced cases
• Hormonal Impact:
  • Reduced cortisol production
  • Decreased aldosterone secretion
  • Altered androgen synthesis
  • Compensatory ACTH elevation

Risk Factors

• Primary pulmonary tuberculosis
• Immunocompromised status
• Malnutrition
• Endemic area residence
• Family history of tuberculosis
• Poverty and overcrowding

Clinical Manifestations

Early Symptoms

• Constitutional Symptoms:
  • Fatigue and weakness
  • Anorexia and weight loss
  • Low-grade fever
  • Night sweats
• Gastrointestinal Symptoms:
  • Nausea and vomiting
  • Abdominal pain
  • Salt craving
  • Food aversion

Addisonian Features

• Skin Changes:
  • Hyperpigmentation (especially in sun-exposed areas)
  • Mucosal pigmentation
  • Palmar creases darkening
• Cardiovascular:
  • Postural hypotension
  • Tachycardia
  • Poor peripheral perfusion
• Metabolic:
  • Hypoglycemia
  • Hyponatremia
  • Hyperkalemia

Growth and Development

• Growth failure
• Delayed puberty
• Poor weight gain
• Muscle wasting

Diagnostic Approach

Laboratory Investigations

• Hormonal Assessment:
  • 8 AM cortisol
  • ACTH levels
  • ACTH stimulation test
  • Plasma renin activity
  • Aldosterone levels
• Metabolic Panel:
  • Serum electrolytes
  • Blood glucose
  • Serum calcium
  • Blood urea nitrogen
• TB Workup:
  • ESR and CRP
  • Tuberculin skin test
  • Interferon-gamma release assay
  • Chest X-ray

Imaging Studies

• CT Findings:
  • Bilateral adrenal enlargement
  • Central necrosis
  • Rim enhancement
  • Calcification in chronic cases
• MRI Features:
  • T1 and T2 signal characteristics
  • Enhancement patterns
  • Mass effect evaluation
• PET-CT:
  • Metabolic activity assessment
  • Other site involvement

Special Procedures

• CT-guided biopsy (when needed)
• Histopathological examination
• PCR for MTB
• Culture studies

Management Protocol

Anti-tubercular Therapy

• Initial Phase (2-3 months):
  • Isoniazid (10 mg/kg/day)
  • Rifampicin (15 mg/kg/day)
  • Pyrazinamide (35 mg/kg/day)
  • Ethambutol (20 mg/kg/day)
• Continuation Phase (4-7 months):
  • Isoniazid
  • Rifampicin

Hormone Replacement

• Glucocorticoid Replacement:
  • Hydrocortisone (8-12 mg/m²/day)
  • Divided doses (3 times daily)
  • Stress dosing during illness
• Mineralocorticoid Replacement:
  • Fludrocortisone (0.05-0.2 mg/day)
  • Dose adjustment based on BP and electrolytes

Supportive Care

• Nutritional support
• Salt supplementation
• Regular monitoring
• Patient education
• Emergency protocols

Complications and Follow-up

Potential Complications

• Acute Adrenal Crisis:
  • Shock
  • Severe hypoglycemia
  • Electrolyte imbalances
  • Altered consciousness
• Chronic Issues:
  • Growth failure
  • Pubertal delay
  • Psychological problems
  • Reduced bone density

Follow-up Protocol

• Regular Monitoring:
  • Growth parameters
  • Blood pressure
  • Electrolytes
  • Hormonal profiles
• Imaging Follow-up:
  • Serial CT scans
  • Response assessment
  • Monitoring for reactivation
• Patient Education:
  • Stress dose education
  • Emergency card carrying
  • Sick day management
  • Regular medication compliance