Epiglottic tuberculosis in a patient treated with steroids for Addison's disease

Tam metin

(1)TohokuJ.Exp.Med. ,200 3,201,1 19-125 Cas eRe por t. Epi gl ot t i cTube r c ul os i si naPat i e ntTr e at e dwi t h St e r oi dsf orAddi s onsDi s e as e SMET EROL EGELI,FATIH OGHAN,MURAT ALPER,UGUR HARPUTLUOGLU andI BULUT. Depar tment of Otor hinolar yngology, Depar tment of Pathology and Depar tment of Pneumology, Duzce Faculty of Medicine, Univer sity of Abant Izzet Baysal, Duzce, Tur key. EGELI,E. ,OGHAN,F. ,ALPER,M. ,HARPUTLUOGLU,U.andBULUT,I . Epiglottic Tuber culosis in a Patient Tr eated with Ster oids forAddison s Disease. TohokuJ . Exp.Me d. ,2 0 0 3 ,2 0 1( 2 ) ,1 1 9 -1 2 5 I s ol at e de pi gl ot t i ct ube r c ul os i s( TBC)i s unc ommonandhasr ar e l ybe e nde s c r i be d. Wer e por tt hec as eofa4 0 ye ar ol d manwi t ht ube r c ul ousi nvol ve me ntoft hee pi gl ot t i sand pr i mar yadr e nali ns uf f i c i e nc y. Endos c opi ce xami nat i on s howe das e ve r e l ys wol l e ne pi gl ot t i s wi t h gr anul omat ousand par t i al l y ne c r ot i cmuc os a. The pat i e nthasbe e nt r e at e d wi t hgl uc oc or t i c oi dsf orf ourye ar sduet opr i mar yadr e noc or t i c ali ns uf f i c i e nc y. Wet he r e f or eas s umet hatt uf e r c ul ousi nvol ve me ntofe pi gl ot t i si sduet ot he r e ac t i vat i on ofpul monar y TBC. We al s o di s c us s di f f e r e nt i aldi agnos i s and manage me ntofe pi gl ot t i cTBCandAddi s onsdi s e as e . e pi gl ot t i ct ube r c ul os i s ;pr i ns uf f i c i e nc y;gl uc oc or t i c oi ds mar yadr e nali Ⓒ2 0 0 3TohokuUni ve r s i t yMe di c alPr e s s. I n1 9 9 3 ,WHO( Wor l dHe al t hOr gani z at i on) de c l ar e dt ot ake pr e c aut i on i mme di at e l yf or t ube nc ul os i s( TBC)t hati sawi de s pr e adc ont agi ousdi s e as e on al love rt he wor l d. I twas t houghtt hatabout9 0mi l l i onpe opl ewoul dbe i nf e c t e dwi t hTBC be t we e nt heye ar sof1 9 9 0 -2 0 0 0 .I n Tur ke y,of f i c i al l yt he numbe r of pe opl ei nf e c t e dwi t hTBCye ar l yi sabout2 20 0 0 -2 70 0 0 ,butt heac t ualnumbe rwase s t i mat e dt o be about 3 50 0 0 -4 00 0 0( Az ap e t al .1 9 9 9 ) . The r e ar es e ve r alr i s kf ac t or sf or TBC i n Tur ke y,s uc h as dr ugs ( e . g. ,ant i c he mot he r s ,c or t i c os t e r oi ds ) ,di s e as e s( e . g. ,HI V) ape ut i c. c aus i ng i mmunos upr e s s i on,and r e s i de nc ei n l ongt e r mc ar ef ac i l i t i e s . Lar ynge alTBC was t he mos tc ommon di s e as ei nvol vi ngt hel ar ynxi nt hee ar l ys t ageof t he t we nt i e t hc e nt ur y( Agar wale tal .1 9 9 8 ) . Today,l ar ynge ali nvol ve me ntofTBCi nf e c t i on i % amongTBCpat i e nt s . Fur t he r sl e s st han1 mor e ,i ti smor ec ommoni nde ve l opi ngc ount r i e st hande ve l ope dc ount r i e s . Cons i s t e ntwi t h t hehi ghi nc i de nc eofhoar s e ne s s ,t hegl ot t i si s t hemos tc ommons i t eofi nvol ve me nt ,butot he r r e gi onsoft hel ar ynx c anbei nvol ve d,s uc has e pi gl ot t i ss e e ni nourc as e .. Rec ei ve dApr i l16 ,2 0 03 ;r e vi s i onac ce pt e df orpubl i cat i onSept e mber17,20 0 3. Addr e s sf orr e pr i nt s :Dr .Fat i h Oghan,AbantI z z etBays alUni ve r s i t e s i ,Duzc eTı pFakul t e s i ,Kul ak Bur unBogazAnabi l i m Dal ı ,8 1 62 0 ,Konur al p,Duzc e/ Tur ke y. emai l :ugur har put l uogl u＠hot mai l . c om 11 9.

(2) 1 20. E.Egel ietal .. The c aus e s ofadr e nali ns uf f i c i e nc y ar e c at e gor i z e d as pr i mar y and s e c ondar y. Pr i mar yadr e nali ns uf f i c i e nc yi sr e l at i ve l yr ar eand mayoc c uratanyage ,andaf f e c t sbot hs e xe s e qual l y. On t he ot he rhand,be c aus e oft he c ommont he r ape ut i cus eofs t e r oi ds ,s e c ondar y adr e nal i ns uf f i c i e nc y i sr e l at i ve l y c ommon ( Wi l l i amse andDl uhy2 0 0 1 ) . Thec ommonf ac t ori n many c as e sofadr e nali ns uf f i c i e nc yi s de s t r uc t i on oft he adr e nalc or t e x,e i t he r by i nf e c t i on oran aut oi mmune me di at e d pr oc e s s , wi t ht hel at t e rbe i ngmor el i ke l y( Br e nne r2 0 0 1 ) . Theadr e nali saf r e que nts i t ef orc hr oni c gr anul omat ous di s e as e s ,pr e domi nant l y TBC butal s ohi s t opl as mos i s ,c oc c i di odomyc os i s ,and c r ypt oc oc c os i s . TBCus e dt ober e s pons i bl ef or 7 0t o9 0 % oft hec as e s ,butt hemos tf r e que nt c aus enow i si di opat hi cat r ophy,whi c hmaybe caus ed by an aut oi mmune mechani s m ( Wi l l i amsandDl uhy2 0 0 1 ) . Hydr oc or t i s onei s t heage ntofc hoi c ef ort het r e at me ntofac ut e adr e nali ns uf f i c i e nc ybe c aus ei tac t sr api dl yand hasbot h gl uc oc or t i c oi d and mi ne r al oc or t i c oi d ac t i vi t y( Br e nne r2 0 0 1 ) . I nt hi sc as er e por twepr e s e ntapat i e ntwi t h e pi gl ot t i cTBCwhohaspr i mar yadr e noc or t i c al i ns uf f i c i e nc y. Eve nt hought hec as e swi t he pi gl ot t i c TBC ar er ar e ,ot or hi nol ar yngol ogi s t s. s houl dke e pi nmi ndt hepos s i bi l i t yofTBC i n t hedi f f e r e nt i aldi agnos i sofl ar ynge alt umor s , as t hei nc i de nc eofTBCi nde ve l opi ngc ount r i e si s s t e adi l yi nc r e as i ng due t oc ur r e ntt e ndi ng i n us i ngi mmunos upr e s s i vet r e at me nt .. CASE REPORT A 4 0ye ar ol dman who had hoar s e ne s s , f at i gue ,we ar i ne s s ,c ough, anor e xi aanddi f f i c ul t yi ns wal l owi ngf orf i f t e e ndaysappl i e dt o ourc l i ni c . Hehad7kgwe i ghtl os sf ort hel as t 2mont hsandhadahi s t or yofs ympt omsofa c ommonc ol df ort hel as t2ye ar s . The r ewas nos moki ngandal c oholhi s t or y. Hehasbe e n t r e at e d wi t ht he r e pl ac e me nt t r e at me nt of me t hyl pr e dni z ol one( 1 6mg/day)andf l udr oc or t i s one( 0 . 1mg/day)f ort hel as t4ye ar sduet o pr i mar yadr e nali ns uf f i c i e nc y. Endos c opi cl ar ynge ale xami nat i onr e ve al e dal e s i onl oc at e don t hee pi gl ot t i sandt hec ont our soft hee pi gl ot t i s we r ei r r e gul ar . Thee pi gl ot t i swass wol l e nand par t i al l y des t r uct ed, wi t h necr ot i c and gr anul omat ousl e s i ons( Fi g. 1 ) . Thel ar ynge al appe ar anc epr ompt e d ust os us pe c tofa c ar c i noma. Thei r r e gul e rl e s i onsoft hee pi gl ot t i s ar el oc al i z e dont hes upe r i ort hi r doft hee pi gl ot t i s . Ot he rl ar ynge alpar t sappe ar e dnott obe af f e c t e d. Che s tXr ays howe dmul t i pl ec avi t i e s. Fi g. 1. The l e s i ons oft he e pi gl ot t i sr e ve al ed by t he f i r s te ndos c opi ce xami nat i on. The e pi gl ot t i swass wol l e nwi t hne cr ot i cmuc os aandgr anul omat ousl es i ons ..

(3) Epi gl ot t i cTube r cul os i si nAddi s onsDi s eas e. 12 1. Fi g. 2. Che s tXr ays howedmul t i pl ec avi t i esandf i br os i swi t hnodul ars hadowi ngi nbot hupper l obe s .. Fi g. 3 . Epi gl ot t i t i swi t hgr anul omas ur r oundedbyl ymphoc yt esandpl as mac e l l s( H & E, ×1 0 0) .. and f i br os i swi t h nodul ars hadowi ng i n bot h uppe rl obe s( Fi g. 2 )andt hee r yt hr oc yt es e di me nt at i on r at e was hi gh r ai s e d at4 0mm/hour . Thec he s tr adi ogr aphyf i ndi ngsr ai s e dt hepos s i bi l i t y ofTBC. Ac i df as tbac i l l ion a Zi e hl Ne e l s e ns t ai nwe r es e e nonmi c r os c opyofs put um and gas t r i cf l ui ds ampl e s . Unde rl oc al ane s t he s i ae ndos c opi cl ar yngos c opywaspe r f or me d;onebi ops ys pe c i me nwass e ntf orbac t e r i ol ogi ce val uat i onandwasf oundt obepos i t i ve f orac i df as tbac i l l i . Myc obac t e r i at ube r c ul os i s. gr e wi ns ubs e que ntc ul t ur e s . Hi s t ol ogi ce xami nat i onofas e c ondbi ops ys pe c i me nf r om e pi gl ot t i s s howe d an e pi t he l i oi d gi ant c e l l gr anul oma wi t h mi c r of oc alc as e ous ne c r os i s s ur r ounde d by l ymphoc yt e sand pl as ma c e l l s ( Fi g. 3 ) . On t he bas i s of t he bac t e r i ol ogi c , r adi ol ogi c ,andhi s t ol ogi cf i ndi ngs ,t hedi agnos i s ofpul monar yTBCwi t he pi gl ot t i ci nvol ve me nt was e s t abl i s he d. For f ur t he rt r e at me nt ,t he pat i e nt was t r ans f e r r e dt ot he pne umol ogy de par t me ntbe c aus et hi si nf e c t i onc oul dbewas.

(4) 1 22. E.Egel ietal .. Fi g. 4. Thegr anul omat ousl es i onsoft hee pi gl ot t i s di s appe ar e daf t erant i t ube r cul oust r eat ment .. s e c ondar yt or e ac t i vat i onoft hepat i e ntspul monar y TBC. The pat i ent was gi ven ant i myc obac t e r i alt he r apyc ompr i s i ngi s oni as i d, r i f ampi c i n, e t hambut ol hydr oc hl or i de , and pyr az i nami de . Wi t hi n 2we e ks ,t he pat i e nts c ondi t i ons mar kedl y i mpr oved. Af t er 6 mont hsoft r e at me nt ,ont hee ndos c opi ce xami nat i ont hel e s i onsoft hee pi gl ot t i sdi s appe ar e d ( Fi g. 4 ) . Hehadagoodr e s pons et ot hi st r e at me ntandhasbe e nf ol l owe dupi nt heout pat i e nt c l i ni c . Al lc ompl ai nt ss uc hashoar s e ne s sand s wal l owi ngdi f f i c ul t i e sdi s appe ar e d.. DISCUSSION The e xi s t i ng pr e val anc ef i gur e sc l e ar l y i ndi c at et hat Addi s ons di s e as e has be c ome mor ec ommon. Be f or e1 9 5 0t hi sdi s e as ewas c l os e l y r e l at e d t o TBC, and i di opat hi c adr e noc or t i c alf ai l ur ewasr ar e( Gut t man1 9 3 0 ) . Wi t ht he de c l i ni ng pr opor t i on oft ube r c ul ous adr e nal i t i s ,t hei nc r e as ei naut oi mmuneadr e nal f ai l ur e hasbe c ome mor ee vi de nt( Lovasand Hus e ybe2 0 0 2 ) . Be c aus eoft hef ac tt hatt he bi ops ys pe c i me n obt ai ne d 4ye ar sago di d not s how anyi nf e c t i ousor i gi ni nt hepr e s e ntc as e , aut oi mmune me di at e d pr oc e s swasc ons i de r e d t ober e s pons i bl ef ort hede s t r uc t i onofadr e nal c or t e x. The pat i e nt has be e nt r e at e d wi t h. c or t i s olandmi ne r al oc or t i c oi dr e pl ac e me ntdue t o pr i mar y adr e nali ns uf f i c i e nc yf or 4ye ar s . Tr e at me ntofot he r me di c alc ondi t i ons wi t h s t e r oi dsc anpot e nt i al l yr e ac t i vat eal at e ntTBC ori nc r e as et her i s kf orpr i mar yi nf e c t i on. Re c e nti nc i de nc eofl ar ynge alTBC i sl e s s t han 1 % among TBC pat i e nt s . Ne dwi c ki ( 1 9 7 0 )de s c r i be d2pat i e nt swhounde r we ntdi r e c t l ar yngos c opy and bi ops y and we r ef ound t o have l ar ynge alTBC. Bul l( 1 9 6 6 )r e por t e d7 pat i e nt swi t hl ar ynge alTBC mas que r adi ngas c ar c i nomas ,and Smal l man e tal .( 1 9 8 7 )r e vi e we d 6c as e sofl ar ynge alTBC i na1 0 ye ar pe r i od. I s ol at e de pi gl ot t i cTBC i sunc ommon buti nt hel as tde c adet he r ehasbe e nac hangi ng pat t e r nofl ar ynge alTBC. Si nghe tal .( 1 9 9 6 ) f ounde pi gl ot t i cTBC i n1oft he i r8nonHI Vpos i t i vepat i e nt s . Kandi l or ose tal .( 1 9 9 7 )r e por t e d9c as e sofl ar ynge alTBCandf oundt he l e s i on i ne pi gl ot t i si n 2c as e s . Thal l e re tal . ( 1 9 8 7 )r e vi e we d1 5pat i e nt swi t hl ar ynge alTBC andf oundonl y1pat i e ntwi t hi s ol at e de pi gl ot t i c i nvol ve me nt . Agar wale tal .( 1 9 9 8 ) ,i nas e r i e s of3 1c as e soft ube r c ul ousl ar yngi t i s ,f ound 1 pat i e ntwi t he pi gl ot t i si nvol ve me ntast heonl y s i t eofl ar ynge all e s i on. Tue tal .( 1 9 9 7 )r e vi e we d4 6pat i e nt swi t hl ar ynge alTBCands t at e d t hatt hee pi gl ot t i swasaf f e c t e di n3 9 % oft he.

(5) Epi gl ot t i cTube r cul os i si nAddi s onsDi s eas e. c as e si naddi t i ont oot he rpar t soft hel ar ynx. Gal l ie tal .( 2 0 0 2 )r e por t e dac as eofi s ol at e d e pi gl ot t i ct ube r c ul os i st hatwaspr e s e nt e dasa l ar ynge alc ar c i noma. Ri c ht e re tal .( 2 0 0 1 )r e por t e dapat i e ntwi t ht ube r c ul ousi nvol ve me nt of t he e pi gl ot t i ss uf f e r i ng f r om uns us pe c t e d pul monar yt ube r c ul os i s . The c l i ni c al s ympt omsofpat i e nt swi t hTBC andc ar c i nomaof t hel ar ynxmaybes i mi l ar ,i nc l udi nghoar s e ne s s , dys phagi a,dys pne a,c ough,and s or et hr oat . Pat i e nt sof t e nr e por ta hi s t or y ofwe i ghtl os s andt obac c ooral c oholabus e( Ramadane tal . 1 9 9 3 ) .I nourc as e ,t he r ewasnos moki ngand al c oholhi s t or ybutwe i ghtl os swaspr e s e nt . Ther e s ur ge nc eofTBC i nt hi sde c adehas af f e c t e d many popul at i ons ,e s pe c i al l y i mmunoc ompr omi s e d pat i e nt s . The s e pat i e nt s may ne e dc or t i c os t e r oi dt he r apy f or var i ous c onc omi t antdi s e as e st hatmi ghtpr e di s pos ea pat i e ntt o de ve l op pr i mar y TBC i nf e c t i on or r e ac t i vat el at e ntTBC i nf e c t i on( Ci s ne r ose tal . 1 9 9 6 ) . Ce l l me di at e di mmuni t y pl ays a ve r y i mpor t antr ol ei nf i ght i ngTBC and,whe r e sby al t e r i ng t hi si mmuni t y, c or t i c os t e r oi ds c an i nc r e as et her i s kofr e ac t i vat i ngl at e ntdi s e as e . Mi l l arand Hor ne( 1 9 7 9 )de s c r i be d1 1pat i e nt s who de ve l ope de i t he rpul monar y ore xt r apul monar y TBC whi l er e c e i vi ng l ongt e r m c or t i c os t e r oi dt he r apy. Haanae sand Be r gmann ( 1 9 8 3 )e val uat e d1 3 5 5c as e sofTBCt ode t e r mi ne how f r e que nt l yt hede ve l opme ntofTBC was as s oc i at e dwi t hc or t i c os t e r oi dt he r apy. I nt he i r s t udy,4 0pat i e nt s( 3 %)hadr e c e i ve dc or t i c os t e r oi dswi t hi n6mont hspr i ort ode ve l opi ngTBC. Al l pat i e nt s de mons t r at e dr e ac t i vat e d TBC i nf e c t i on;none de ve l ope d a ne w i nf e c t i on. Be c aus eoft hef ac tt hataut oi mmunede f i c i e nc y s yndr ome( AI DS)andot he ri mmunos uppr e s s i ve di s e as e s or t r e at me nt s may c ont r i but et o i nc r e as et hei nc i de nc eands pe c t r um oft ube r c ul os i s ,weal s oi nve s t i gat e dt hepr e s e nc eofs uc h i nf e c t i onsanddi s e as e sby hi s t or y and l abor at or ys t udi e s .I nourc as e ,webe l i e vet hatTBC hasbe e nr e ac t i vat e dduet ol ongt e r mc or t i c os t e r oi d r e pl ac e me nt t he r apy. Cor t i c os t e r oi ds. 12 3. de mons t r at ebot hadve r s eandbe ne f i c i ale f f e c t s i npat i e nt swi t hTBC. St e r oi dsmayadve r s e l y s uppr e s s or modi f yc e l l me di at e di mmuni t y ( Mas udandKe mp1 9 8 8 ) . Tube r c ul i nr e ac t i vi t y i sr e duc e daf t e rpat i e ntr e c i e ve spr e dni s one1 5 mg/day( ore qui val e nt )f or2 -3we e ks( Se l wyn e tal .1 9 8 9 ) . Fr e nke l( 1 9 6 0 )pr e s e nt e de vi de nc e f ort hevi e wt hatt hee ndoge nouss t e r oi dsoft he adr e nalc or t e xpe r mi t t e dt hes e l e c t i ve ,pr ogr e s s i ve mul t i pl i c at i on oft ube r c ul e bac i l l iwhi c h r e s ul t e di nAddi s onsdi s e as e .I ti sc l e ar ,t he r e f or e ,t hate xc e s s i vegl uc oc or t i c oi dsr e duc er e s i s t anc et oi nf e c t i on i n ge ne r al . Cor t i c os t e r oi ds ar eus e dasr e pl ac e me ntt he r apyi npat i e nt swho de ve l opAddi s onsdi s e as es e c ondar yt ot ube r c ul ousi nf e c t i on( De done tal .1 9 9 2 ) .I nourc as e , t hepat i e nthadbe e nt r e at e dwi t hs t e r oi dsduet o Addi s onsdi s e as et hati sc aus e dby i di opat hi c at r ophy of adr e nal gl ands . Aut oi mmune Addi s onsdi s e as ec ande ve l ops l owl yove rmany ye ar sbe f or es ympt omsappe ar( Te ne tal .2 0 0 1 ) . Thepat i e nt s ,whowe r ei ns t r uc t e dt os pe nd al ar gepar toft he i rt i medur i ngt he i ri l l ne s si n be d,t e nde dt ode ve l opl e s i onsoft hepos t e r i or l ar ynx ( Soda e tal .1 9 8 9 ) . Ourpr e s e nts t udy agr e e swi t ht her e por t s( Ande r s onandSt e ve ns 1 9 8 1 ;Es pi noz ae tal .1 9 8 1 ;Hunt e rand Mi l l ar 1 9 8 1 ;Le ve ns on e t al .1 9 8 4 )t hat l ymphat i c / he mat oge ni cs pr e adanddi s e as eoft heant e r i or l ar ynxi snow mor ec ommonl ye nc ount e r e d. I n ourc as e ,TBCl e s i onwasl i mi t e dt ot hee pi gl ot t i s ,butwasi ni t i al l ys us pe c t e dofane pi gl ot t i c mal i gnancy. Howe ve r , unl i ke our c as e, pat i e nt swi t hmal i gnanc yar eus ual l yol de rt han 6 0ye ar sage ,wi t hahi s t or yofhe avys moki ng andal c ohol .I ti st he r e f or ei mpor t antt onot e t hatt he TBC l e s i ons c an be c onf us e d wi t h l ar ynge alt umor s . Fori ns t anc e ,Khan ( 1 9 8 3 ) r e por t e dac as eoft ube r c ul ousgr anul omaoft he e pi gl ot t i st hatr e s e mbl e dc ar c i noma on l ar yngos c opi c e xami nat i on, and onl y hi s t ol ogi c e xami nat i onoft hebi ops ymat e r i alwasdi agnos t i c . Ourc as es ugge s t st hatt hephys i c i ans de al i ngwi t ht hepat i e nt swhohasbe e nt r e at e d wi t hs t e r oi dss houl dbeawar eoft hepos s i bi l i t y.

(6) 1 24. E.Egel ietal .. ofl ar ynge alTBC and s houl d be c ar e f ult o di s t i ngui s ht hel e s i on f r om t umor sorc hr oni c l ar yngi t i s . Re f e r e nc e s Agar wal ,P.& Bai s ,A. S.( 1 9 9 8 )A c l i ni c aland vi de os t r obos c opi ce val uat i on of l ar ynge al t ube r c ul os i s . J. Lar yngol. Otol . ,1 1 2 ,4 5 4 8 . Ande r s on,C. W.& St e ve ns ,M. H.( 1 9 8 1 ) Sync hr onoust ube r c ul ousi nvol ve me ntofbot he ar s andt hel ar ynxi napat i e ntwi t hac t i vepul monar ydi s e as e . Lar yngoscope,9 1 ,9 0 6 -9 0 9 . Az ap,A.( 1 9 9 9 ) Tube r kul ozi ns anl i git e hdi te t me ye de vam e di yor . Tip dunyasi ,1 ,5 3 . Br e nne r ,K.( 2 0 0 1 )I nde x of s us pi c i on. Pediatr . Rev. ,2 2 ,2 4 5 2 5 0 . Bul l ,T. R.( 1 9 6 6 ) Tube r c ul os i soft hel ar ynx. Br . Med. J . ,2 ,9 9 1 -9 9 2 . Ci s ne r os ,J . R.& Mur r ay,K. M.( 1 9 9 6 ) Cor t i c os t e r oi dsi nt ube r c ul os i s . Ann. Phar macother. ,3 0 , 1 2 9 8 1 3 0 3 . De don,J . F. ,Cour t ne y,D. L.& Hol me s ,F. F.( 1 9 9 2 ) Addi s onsdi s e as ef r om t ube r c ul os i si nac e nt e nar i an. J. Am. Ger iatr . Soc . ,4 0 ,6 1 8 6 1 9 . Es pi noz a,C. G. ,Mont ano,P.& Saba,S. R.( 1 9 8 1 ) Lar ynge al t ube r c ul os i s . Lar yngoscope, 9 1 , 1 1 0 1 1 3 . Fr e nke l ,J . K.( 1 9 6 0 ) Pat hoge ne s i sofi nf e c t i onsof adr e nalgl andl e adi ngt oAddi s onsDi s e as ei n man:Rol eofc or t i c oi dsi nAdr e nalandge ne r al i z e di nf e c t i on. Ann. NY. Acad. Sci . ,8 4 , 3 9 1 4 4 0 . Gal l i ,J . ,Nar di ,C. ,Cont uc c i ,A. M. ,Cadoni ,G. ,Laur i ol a,L.& Fant oni ,M.( 2 0 0 2 ) At ypi c ali s ol at e de pi gl ot t i ct ube r c ul os i s :ac as er e por tand ar e vi e w oft hel i t e r at ur e . Am. J. Otolar yngol . ,2 3 ,2 3 7 2 4 0 . Gut t man,P. H.( 1 9 3 0 ) Addi s onsdi s e as e .A s t at i s t i c alanal ys i s off i ve hundr e d and s i xt ys i x c as e sand a s t udy oft hepat hol ogy. Ar ch. Pathol . ,1 0 ,7 4 2 7 8 5 . Haanae s , O. 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