Secondary adrenal insufficiency in a young man with HIV and pulmonary tuberculosis, complicated by cerebral toxoplasmosis and seizure

Abstract

Secondary adrenal insufficiency (SAI) presents with non-specific clinical symptoms, which may overlap with those of HIV and tuberculosis, making diagnosis challenging. We report a case of a 22-year-old Indonesian man, presented with fatigue, intermittent dyspnea, intermittent nocturnal fever, and a significant weight loss of 5 kg over one month. He also reported having unprotected sex with a casual partner. Physically, he presented pale and weak with hypotension . Laboratory examination showed cortisol levels of 28.46 nmol/L and adrenocorticotropic hormone (ACTH) levels of 5.6 µg/dL. Chest x-ray and GeneXpert confirmed pulmonary tuberculosis. Despite an initial negative HIV examination, repeat testing was recommended due to the possibility of a false-negative result. Therefore, the initial diagnosis was SAI due to HIV and tuberculosis. He was treated with hydrocortisone and supportive therapy. Following outpatient discharge, he was re-admitted due to severe headaches, vomiting, and a generalized tonic-clonic seizure. Neuroimaging revealed ring-enhancing lesions, and serology testing was positive for toxoplasmosis IgG and IgM. Repeat testing of HIV was positive with very lowCD4 count. The final diagnosis was cerebral toxoplasmosis, newly diagnosed HIV, and disseminated tuberculosis infection. He responded well to the treatment for 20 days without any complaints and was discharged with anti-retroviral (ARV) and anti-tuberculosis drug (ATD) alongside toxoplasmosis treatment. He remained clinically stable at a 5-months follow-up. Early recognition and treatment of SAI to prevent life-threatening complications, particularly in patients with HIV and tuberculosis co-infection. Thus, early recognition and management are critical to minimize severe complications, particularly cerebral toxoplasmosis.