Postgrad Med J (1993) 69, 832- 834
© The Fellowship of Postgraduate Medicine, 1993
Letters to the Editor
Recovery of adrenocortical function following treat-
ment oftuberculous Addison's disease
Penrice and Nussey report two cases ofAddison's disease
in which adrenocortical function recovered following
treatment of tuberculosis.' Adrenal glands may be
enlarged or atrophic in patients with Addison's disease
due to t iberculosis. Large glands in tuberculosis mean a
recent and probably active infection requiring treatment,
whereas small calcified glands are in favour ofremote and
probably inactive infection.2 Renner et al. reported two
cases ofadrenal tuberculosis in which adrenal glands had
been enlarged and they concluded that computerized
noninvasive diagnosis of tuberculous adrenalopathy.3 In
another report, the finding ofenlarged adrenal glands on
CT suggested the presence ofearly tuberculosis or in rare
instances other potentially treatable diseases.4
Barnes et al. investigated adrenal function in 90
patients with active tuberculosis (30 pulmonary, 30
miliary, 30 extrapulmonary) before and after starting
anti-tuberculous therapy. They found some degree of
adrenal dysfunction in seven patients. After the treat-
ment, the Synacthen response returned to normal in all
but one patient, and they concluded that adrenal dysfunc-
tion is an uncommon problem in patients with active
favourable effect on adrenal function.'
Recently we have reported a patient with active
pulmonary tuberculosis, acute adrenal failure and an
enlarged adrenal mass demonstrated by CT.6 The mass
was removed surgically and histopathologic examination
disclosed adrenal tuberculoma. We have also shown that
adrenal glands are larger in acute pulmonary tuberculosis
than that in chronic tuberculosis and also healthy sub-
jects.' CT scanning was not carried out in the patients
reported by Penrice and Nussey. Since the symptoms and
signs ofAddison's disease appear after more than 90% of
the glands have been destroyed by tuberculosis,8 we think
that recovery of adrenal insufficiency is not possible in
patients with Addison's disease due to remote tuber-
culosis in which adrenal glands are atrophic and calcified.
In contrast, recovery of adrenocortical function after
anti-tuberculous therapy in reported patients with tuber-
culosis is an expected outcome.2.9
We suggest that CT ofadrenal glands should be carried
out in every patient presenting with Addison's disease
thought to be caused by tuberculosis. If there is adrenal
atrophy anti-tuberculous therapy may not be required. If
adrenal glands are enlarged, anti-tuberculous therapy
may be needed.
( T) is the method of choice for the
1. Penrice, J. & Nussey, S.S. Recovery ofadrenocortical function
following treatment of tuberculous Addison's disease. Post-
grad Med J 1992, 68: 204-205.
2. McMurry, J.F., Long, D., McLure, R. & Kotchen, T.A.
Addison's disease with adrenal enlargement on computed
tomographic scanning. Report oftwo cases oftuberculosis and
review of the literature. Am J Med 1983, 77: 365-368.
3. Renner, F., Karnel, F., Graninger, W. & Imhof, H. Morbus
addison mit sonographisch und computertomographisch
uberlegungen and hand zweiner
adrenalitis. Wien Klin Wochenschr 1986, 98: 244-249.
4. Vita, J.A., Silverberg, S.J., Goland, R.S., Austin, J.H.M. &
Knowlton, A.I. Clinical clues to thecauseofAddison's disease.
Am J Med 1985, 78: 461-466.
5. Barnes, D.J., Naraqi, S., Temu, P. & Turtle, J.R. Adrenal
function in patients with active tuberculosis. Thorax 1989, 44:
6. Keletimur, F., Ozbakir, O., Saglam, A., Ozturk, F. &
Yiucesoy, M. Acute adrenocortical failure due to tuberculosis.
J Endocrinol Invest. 1993, 16: 281-284.
6.Kele§timur,F., Unlui, Y., Ozesmi, M. & Tolu, 1. A hormonal
and radiological evaluation of adrenal gland in patients with
acute and chronic pulmonary tuberculosis. J Endocrinol 1993,
137 (Suppl): P26 (Abstract).
8. Williams, G.H. & Dluhy, R.G. Disease of the adrenal cortex.
In: Braunwald, E. (ed.) Harrison's Principles of Internal
Medicine. McGraw Hill (International edition), Hamburg,
1987, pp. 1753- 1774.
9. Ellis, M.E. &Tayoub, F. Adrenal function in tuberculosis. BrJ
Dis Chest 1986, 80: 7-12.
falle von tuberkuloser
Guillain-Barre syndrome in a patient with chronic
Guillain-Barre syndrome (GBS) has been frequently
especially those of the lymphoid system, for example,
Hodgkin's disease.' However, despite being the com-
monest lymphoid malignancy,
leukaemia has been associated with GBS in only three
reported patients.2'3 I describe a fourth case.
A 77 year old woman with known stage III B-cell
chronic lymphocytic leukaemia (CLL) presented with a
5-day history of progressive symmetrical limb weakness,
distal limb parasthesiae and breathlessness. There was no
history ofrecent viral infection. CLL had been diagnosed
3 months before and treated with chlorambucil as well as
a blood transfusion. Chlorambucil was stopped 8 weeks
later because ofmyelosuppression. Examination revealed
a frail, breathless, afebrile lady with moderate hepato-
splenomegaly. The cranial nerves were normal. She had a
flaccid quadriparesis with generally MRC grade 2 power,
absent tendon reflexes and flexor plantar responses. There
was impaired appreciation of vibration and propriocep-
tion below the ankles.
Investigation revealed a reduced forced vital capacity
of 1.2 litres. Routine biochemistry was normal. Her
haemoglobin was 1.5 g/dl and herlymphocyte count was
99.9 x 109/l. A direct Coombs' test was negative. Paired
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