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4HE ENDOCRINOLOGY OF ADRENAL TUBERCULOSIS 4HE EFFECTS OF
TUBERCULOSIS ON THE HYPOTHALAMO
PITUITARY
ADRENAL AXIS
Y
AND ADRENOCORTICAL FUNCTION
& +ELESTIMUR
$IVISION OF %NDOCRINOLOGY $EPARTMENT OF -EDICAL 3CIENCES 5NIVERSITY OF %RCIYES +AYSERI 4URKEY
!"342!#4 4UBERCULOSIS MAY AFFECT MANY OF THE LOSIS AND RECENT FINDINGS REVEALED THAT (0! AXIS
ENDOCRINE GLANDS INCLUDING THE HYPOTHALAMUS IS ACTIVATED RATHER THAN UNDERACTIVATED IN ACTIVE
PITUITARY THYROID AND ADRENALS 4HE MOST COM
PULMONARY TUBERCULOSIS !CTIVATED (0! AXIS IN
MONLY INVOLVED ENDOCRINE ORGAN IN TUBERCULOSIS IS TUBERCULOSIS CAUSES INCREASED CORTISOL SECRETION
THE ADRENAL GLAND !DRENAL GLANDS MAY BE DIRECTLY WHICH RESULTS IN A SHIFT IN THE 4H4H BALANCE TO
OR INDIRECTLY AFFECTED BY TUBERCULOSIS 4UBERCULOUS WARDS 4H 4 CELL DYSFUNCTION DUE TO HIGH CORTISOL
!DDISONS DISEASE IS STILL AN IMPORTANT CAUSE OF PRI
AND LOW $(%!3 LEVELS MAY BE RESPONSIBLE FOR IM
MARY ADRENOCORTICAL INSUFFICIENCY PARTICULARLY IN MUNOLOGICALLY
MEDIATED TISSUE DAMAGE IN TUBER
R
THE DEVELOPING COUNTRIES 2ECENT IMPROVEMENTS CULOSIS )N THIS REVIEW RECENT FINDINGS CONCERNING
IN IMAGING TECHNIQUES AND MODERN ENDOCRINOLOGI
THE ADRENOCORTICAL FUNCTION RADIOLOGICAL CHANGES
CAL TESTS FOR THE INVESTIGATION OF ADRENAL FUNCTION IN ADRENAL GLANDS AND (0! AXIS INVOLVEMENT IN TU
HAVE GIVEN US GREATER INSIGHT INTO THE ENDOCRINOL
BERCULOSIS ARE DISCUSSED
OGY OF ADRENAL TUBERCULOSIS (YPOTHALAMO
PITUI
* %NDOCRINOL )NVEST
TARY
ADRENAL (0! AXIS IS ALSO INVOLVED IN TUBERCU
¥
%DITRICE +URTIS
).42/$5#4)/. ARE SHOWN IN 4ABLE 4HE MOST COMMONLY INVOLVED
4UBERCULOSIS IS THE LEADING INFECTIOUS CAUSE OF DEATH ENDOCRINE ORGAN IN TUBERCULOSIS IS THE ADRENAL GLAND
IN THE WORLD !LTHOUGH THE INCIDENCE OF TUBERCULOSIS 4HE RELATION BETWEEN THE ADRENAL GLANDS AND TUBER
R
HAS DECLINED IN DEVELOPED COUNTRIES THE DISEASE CULOSIS HAS BEEN KNOWN FOR MORE THAN A CENTURY
CONTINUES TO BE AN IMPORTANT PUBLIC HEALTH PROBLEM 2ECENT DEVELOPMENTS IN IMAGING TECHNIQUES AND
4HE 7ORLD (EALTH /RGANIZATION PREDICTS CON
MODERN ENDOCRINOLOGICAL TESTS FOR THE INVESTIGATION
TINUED INCREASES IN TUBERCULOSIS AND AN ESTIMATED OF ADRENAL FUNCTION HAVE GIVEN US GREATER INSIGHT INTO
WORLDWIDE INCIDENCE OF NEARLY MILLION CASES THE ENDOCRINOLOGY OF ADRENAL TUBERCULOSIS )N THIS RE
EACH YEAR BY !LL ORGAN SYSTEMS MAY BE VIEW RECENT FINDINGS CONCERNING THE ADRENOCORTICAL
INVOLVED IN TUBERCULOSIS AND IT MAY AFFECT MANY OF THE FUNCTION AND HYPOTHALAMO
PITUITARY
ADRENAL (0!
ENDOCRINE GLANDS INCLUDING THE HYPOTHALAMUS PITUI
AXIS INVOLVEMENT IN TUBERCULOSIS ARE DISCUSSED
TARY AND THYROID !LTHOUGH WE HAVE RECENTLY SHOWN
THAT TUBERCULOSIS DOES NOT CAUSE HYPERCALCEMIA CAL
!$$)3/.3 $)3%!3%
CIUM AND VITAMIN $ METABOLISM HAVE BEEN ACCEPTED
AS OTHER IMPORTANT SYSTEMS AFFECTED BY TUBERCULOSIS 4HE CHRONIC TYPE OF HYPOADRENALISM WAS FIRST DE
4HE ENDOCRINE ABNORMALITIES DUE TO TUBERCULOSIS SCRIBED BY 4HOMAS !DDISON OF 'UYS (OSPITAL IN
AND THE TERM @!DDISONS DISEASE IS NOW USED
TO REFER TO ALL FORMS OF CHRONIC PRIMARY ADRENOCORTI
CAL INSUFFICIENCY WHATEVER THE PATHOLOGICAL CAUSE
+EY
WORDS !DRENAL TUBERCULOSIS !DDISON (0! AXIS !#4( TEST
OF DAMAGE TO THE ADRENAL GLANDS 3EVENTY YR
#ORRESPONDENCE & +ELESTIMUR -$ $EPARTMENT OF %NDOCRINOLOGY AGO IT WAS DEMONSTRATED THAT APPROXIMATELY OF
%RCIYES 5NIVERSITY -EDICAL 3CHOOL +AYSERI 4URKEY PATIENTS WITH !DDISONS DISEASE WAS DUE TO TUBERCU
%
MAIL FKTIMUR YAHOOCOUK LOSIS ! STUDY OF PATIENTS WITH !DDISONS DISEASE
!CCEPTED *ULY CARRIED OUT MORE THAN YR AGO INDICATED THAT
& +ELESTIMUR
!$2%.!, 45"%2#5,/3)3 C D
4UBERCULOSIS MAY DIRECTLY INVOLVE THE ADRENAL GLANDS
AS SEEN IN !DDISONS DISEASE WHICH CLASSICALLY AP
PEARS AFTER MORE THAN OF THE GLANDS HAS BEEN
DESTROYED BY TUBERCULOSIS !DRENAL TUBERCULOSIS
FOLLOWING HAEMATOGENOUS DISSEMINATION IS OFTEN NOT
APPARENT FOR AS MANY AS YR AFTER INFECTION WHEN
!DDISONS DISEASE APPEARS IN THE FORM OF DEGEN
E
ERATION OF THE CORTEX )N A RECENT AUTOPSY STUDY &IG
A #ASE #OMPUTED TOMOGRAPHY SCAN SHOWS ENLARGED
ADRENAL TUBERCULOSIS WAS SEEN IN OF THE PATIENTS RIGHT ADRENAL GLAND IN A PATIENT WITH ACUTE ADRENAL FAILURE AND AC
WITH ACTIVE TUBERCULOSIS AND IN OF THESE PATIENTS TIVE PULMONARY TUBERCULOSIS B #ASE 5NILATERAL ADRENAL ENLARGE
THE ADRENAL GLAND WAS THE ONLY ORGAN INVOLVED BY MENT IN A PATIENT WITH NEWLY DIAGNOSED TUBERCULOUS !DDISONS
TUBERCULOSIS 3INCE MODERN IMAGING TECHNIQUES DISEASE C #ASE "ILATERAL SMALL ADRENALS OF THE SAME PATIENT
YR LATER D #ASE "ILATERAL SMALL CALCIFIED ADRENALS IN A PATIENT
HAVE BEEN DEVELOPED OUR KNOWLEDGE ABOUT THE WITH TUBERCULOUS !DDISONS DISEASE E #ASE "ILATERAL SLIGHTLY EN
APPEARANCE OF THE ADRENAL GLAND IN TUBERCULOSIS AND LARGED AND CALCIFIED RIGHT ADRENAL GLANDS IN A PATIENT PRESENTING
ITS RELATION TO THE STAGE OF INFECTION HAS SIGNIFICANTLY MILIARY TUBERCULOSIS AND !DDISONIAN CRISIS INDUCED BY RIFAMPICIN
(0! AXIS AND ADRENAL TUBERCULOSIS
& +ELESTIMUR
!DRENAL SIZE
%NLARGED WITH OR WITHOUT CALCIFICATION 3MALLCALCIFIED
%ARLY TUBERCULOSIS 2EMOTE TUBERCULOSIS
.ORMAL ADRENOCORTICAL !DRENOCORTICAL FAILURE
FUNCTION
&IG
!DRENAL SIZE AND ITS RELATION TO
4HE EFFECTIVENESS OF ANTI
TUBER
F CULOSIS !NTI
TUBERCULOSIS THERAPY ANTI
TUBERCULOSIS THERAPY IN TUBERCULOUS
TREATMENT IS NOT CLEAR IS NOT REQUIRED !DDISONS DISEASE
(0! AXIS AND ADRENAL TUBERCULOSIS
β PROTEINS AND M2.! FROM MONONUCLEAR PHAGOCYTES ORGAN IN TUBERCULOSIS IS THE ADRENAL GLAND !LTHOUGH
-YCOBACTERIUM TUBERCULOSIS CELL
WALL COMPONENT AUTOIMMUNE ADRENALITIS HAS SUPPLANTED TUBERCULOSIS
,!- ACTS SIMILARLY TO ,03 IN ACTIVATING MONONUCLEAR AS THE MOST COMMON CAUSE OF PRIMARY ADRENAL INSUF
F
PHAGOCYTE CYTOKINE 4.&
α AND ),
α β -YCOBACTE
FICIENCY TUBERCULOUS !DDISONS DISEASE IS STILL AN IM
RIUM TUBERCULOSIS
REACTIVE HUMAN 4
CELL CLONES SECRETE
S PORTANT CAUSE OF PRIMARY ADRENOCORTICAL INSUFFICIENCY
A WIDE VARIETY OF CYTOKINES INCLUDING INTERFERON )&.
γ
PARTICULARLY IN DEVELOPING COUNTRIES !DRENAL GLANDS
4.& ),
),
ANDOR ),
IN RESPONSE TO -YCOBACTE
MAY BE DIRECTLY OR INDIRECTLY AFFECTED BY TUBERCULOSIS
RIUM TUBERCULOSIS "ARNES ET AL HAVE ALSO SUG
S
$IRECT INVOLVEMENT OF ADRENALS BY TUBERCULOSIS RESULTS
GESTED THAT THE CYTOKINE PRODUCED IN THE HIGHEST CON
IN TUBERCULOUS !DDISONS DISEASE !DRENAL GLANDS ARE
CENTRATIONS IS 4.&