Adrenal Insufficiency Caused by Paracoccidioidomycosis: Three Case Reports and Review

ABSTRACT Objective Fungal infections can affect the adrenal glands, causing primary adrenal insufficiency (PAI). Although endemic to South America, paracoccidioidomycosis (PCM), which can lead to PAI, has gained global relevance with the increase in international travel and migration. Methods The present report describes 3 patients with PAI caused by PCM. Results Patients in cases 1 and 2 both reported indisposition, asthenia, nausea, hyperpigmentation of the skin, hypotension, and weight loss. Complementary exams confirmed PAI due to PCM. Case 1 was serologically diagnosed. In contrast, the definitive diagnosis of case 2 was only reached by computed tomography (CT)-guided adrenal biopsy after negative serologies for PCM. Case 3, with diabetes mellitus, had a history of asthenia, nausea and weight loss after persistent sinusitis. Initially, serologic results were negative for PCM and the patient's CT-guided biopsy resulted in insufficient tissue to obtain a definitive diagnosis. Contrary to the initial hypothesis of invasive aspergillosis, since the only etiological evidence for the patient's clinical condition were positive serologies for Aspergillus fumigatus, histopathologic examination of the specimen provided by a left adrenalectomy finally confirmed PCM as the etiology for PAI in this case as well. Conclusion The 3 cases illustrate the necessity to investigate PAI whenever there are suspicious clinical findings. They also show that fungal infections should be considered among the diagnostic hypotheses during the etiological investigation of PAI. Finally, they teach us that definitive diagnosis of PCM may require direct visualization of the pathogen.