Adrenal Involvement in Disseminated Histoplasmosis

Abstract

A 28-year-old woman presented to the hospital with a 6-month history of dry cough. She was a lifetime nonsmoker and reported having no fevers, joint aches, eye pain, or rashes. On physical examination, auscultation of both lower lungs revealed fine crackles. High-resolution computed tomography (CT) of the chest showed mediastinal lymphadenopathy and diffuse ground-glass opacities (Panel A, axial view). Also visible were areas of superimposed interlobular and intralobular septal thickening, a pattern known as crazy paving because of the resemblance to irregular paving stones (Panel A, box). The serum level of angiotensin-converting enzyme was 80 U per liter (reference range, 17 to 55). A subsequent transbronchial lung biopsy showed multiple noncaseating granulomas (Panel B, inset showing granuloma; hematoxylin and eosin stain). Bronchoalveolar-lavage cultures, histopathological analysis, and molecular testing were negative for infectious organisms, including Mycobacterium tuberculosis. A diagnosis of pulmonary sarcoidosis was made. The crazy-paving pattern is commonly associated with pulmonary alveolar proteinosis, but it is also seen in a variety of other conditions, such as acute respiratory distress syndrome, Pneumocystis jirovecii pneumonia, and sarcoidosis, as in this case. A tapering dose of prednisone was initiated. By 6 months after the initiation of treatment, the patient's symptoms had abated and the radiographic findings had greatly improved (Panel C). At that point, pred-nisone was discontinued, and the patient's condition stabilized. The associated symptoms did not recur, and repeat chest CT after 1 year of follow-up did not suggest progression of the lesions.