Out of Site, Out of Mind- A Rare Case of Adrenal Histoplasmosis from a Non Endemic Area

There has been a rising trend in the number of histoplasmosis cases reported in the recent years. However, in southern India, the number of cases is relatively less. This report is about a 46-year-old Indian male from Tamil Nadu who presented with decreased appetite, vomiting, and giddiness. In view of persistent hyponatremia and hypotension, a work-up for adrenal insufficiency was done, and serum cortisol was found to be low. Contrast Enhanced Computed Tomography (CECT) showed bilateral adrenal enlargement with peripheral rim enhancement and hypodense areas within. There was a diagnostic dilemma between tubercular and fungal aetiology. Fine Needle Aspiration Cytology (FNAC) of the adrenal gland showed features suggestive of histoplasmosis. The patient was treated with itraconazole along with steroid replacement therapy, leading to marked improvement in his overall condition. In immunocompetent individuals, disseminated histoplasmosis with adrenal gland involvement is a rare occurrence. As an unusual presentation of histoplasmosis, this case adds to the body of literature available from Tamil Nadu, which is a non endemic region for histoplasmosis, with only 15 cases being reported as of 2018.