Diagnosis of left adrenal paracoccidioidomycosis by endoscopic ultrasound fine needle aspiration

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Paracoccidioidomycosis is a systemic granulomatous disease endemic in Latin America. It is acquired through the inhalation of spores released by Paracoccidioides brasiliensis [1]. Impairment of adrenal function may be found in 15 % – 20 % of patients with paracoccidioidomycosis [1]. Although highly specific (> 85 %), serological tests may be false-negative in immunosuppressed patients [1]. Hence, detection of fungal elements is the diagnostic gold standard. A PubMed review revealed that adrenal biopsies done to diagnose paracoccidioidomycosis are mostly guided either by computed tomography or by abdominal ultrasound [2] [3]. This is the first case report of diagnosis of paracoccidioidomycosis in the left adrenal gland by endoscopic ultrasound fine needle aspiration (EUS-FNA).

A 40-year-old man with chronic alcoholic pancreatitis and type 2 diabetes mellitus complained of weakness, abdominal pain, and 30 kg of weight loss in the past 6 months. During the diagnostic investigation, primary adrenal insufficiency was confirmed by the low serum cortisol and high levels of adrenocorticotropic hormone (ACTH). A magnetic resonance scan showed nodular formation (3.5 × 2.4 × 4.7 cm) in the left adrenal gland ([Fig. 1]). As the patient had a positive history for tuberculosis and paracoccidioidomycosis, he was investigated for presence of these pathogens. Catarrh assessment revealed absence of both paracoccidioidomycosis and tuberculosis organisms and serological tests were also negative. Endoscopic ultrasonography with FNA was carried out ([Fig. 2]) and the histopathological analysis revealed P. brasiliensis spores ([Fig. 3]). The patient was treated with amphotericin-B with complete remission after 60 days.

Fig. 1 Magnetic resonance image showing nodular formation in the left adrenal gland (arrow).

Fig. 2 Endosonography: fine needle aspiration of the left adrenal gland.

Fig. 3 Histopathological section showing spores with black capsules (arrow) (Grocott silver stain, × 40).

Percutaneous adrenal puncture has been standard practice in the diagnosis of paracoccidioidomycosis of the adrenal gland, with severe complications reported such as hematuria, pancreatitis, and pneumothorax [4]. Nowadays, EUS-FNA of the left adrenal is a safe and reliable method, with low morbidity and high rate of accuracy [5], and this is the first report of diagnosis of adrenal paracoccidioidomycosis by EUS-FNA.

Endoscopy_UCTN_Code_CCL_1AF_2AG_3AD

Competing interests: None

References

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