Imaging studies help in the evaluation of affected adrenal glands ( Figure 1). While few studies have demonstrated elevated basal and stimulated cortisol levels, others have shown lower cortisol levels. Stress and inflammation are thought to be underlying reasons for adrenal enlargement in patients with tuberculosis without microbial seeding of the glands. At least 90% of the adrenal gland must be involved with parenchymal destruction before clinical features of adrenal insufficiency appear. Tuberculosis must be suspected in patients with a fever along with adrenomegaly. Clinical manifestations may take years to appear while others may have asymptomatic infections. Adrenal glands are infected through a hematogenous route. In one reported series, the incidence of adrenal involvement was 6% of patients with active tuberculosis.
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