Rev Esp Med Nucl Imagen Mol. 2016;35(4):257–259 Clinical note Adrenal tuberculosis masquerading as disseminated malignancy: A pitfall of 18 F-FDG PET/CT Imaging A.K.R. Gorla a , K. Gupta b , A. Sood a,∗ , C.K. Biswal a , A. Bhansali c , B.R. Mittal a a Department of Nuclear Medicine, PGIMER, Chandigarh 160012, India b Department of Histopathology, PGIMER, Chandigarh 160012, India c Department of Endocrinology, PGIMER, Chandigarh 160012, India a r t i c l e i n f o Article history: Received 18 October 2015 Accepted 26 November 2015 Available online 4 February 2016 Keywords: Adrenal insufficiency Tuberculosis 18 F-fluorodeoxyglucose positron-emission tomography Computed tomography Needle biopsy a b s t r a c t Non-invasive characterization of adrenal lesions is a commonly encountered diagnostic challenge. Cha- racteristic clinical and correlative imaging findings may assist in only arriving at a probable diagno- sis. Currently, 18 F-FDG PET/CT is considered to provide the most comprehensive imaging information. We here present a case of bilateral adrenal tuberculosis that highlights the need for caution during the interpretation of 18 F-FDG PET/CT and also the need to suggest histopathological correlation. © 2016 Elsevier Espa ˜ na, S.L.U. y SEMNIM. All rights reserved. Tuberculosis adrenal que simula una enfermedad maligna diseminada: probable error diagnóstico de la imagen PET/TC con 18 F-FDG Palabras clave: Insuficiencia suprarrenal Tuberculosis Tomografía por emisión de positrones/Tomografía computarizada con 18 F-fluorodesoxiglucosa Biopsia r e s u m e n La caracterización no invasiva de las lesiones suprarrenales es un frecuente desafío diagnóstico. Las características clínicas y la correlación con los hallazgos de las técnicas de imagen pueden sugerir un diagnóstico probable, siendo en la actualidad la PET/TC con 18 F-FDG la técnica que proporciona la mayor información. Presentamos un caso de tuberculosis suprarrenal bilateral que destaca la necesidad de ser prudentes en la interpretación de la PET/TC con 18 F-FDG y la necesidad de su correlación histopatológica. © 2016 Elsevier Espa ˜ na, S.L.U. y SEMNIM. Todos los derechos reservados. Introduction Accurate characterization of adrenal pathology is achieved only by invasive methods like histopathology. However, pathognomonic imaging findings and specific patterns of involvement can often suggest possible etiology. Hybrid imaging with 18 F-FDG PET/CT can be a potentially useful tool in such situations as it provides the combined anatomical and functional information. 1 We here report an uncommon case of bilateral adrenal tuberculosis that mimicked malignant involvement of adrenal glands on 18 F-FDG PET/CT and thus highlighting the need for caution during interpretation. Case report A 50-year male patient presented with acute onset vomiting for 3 days in the emergency ward. Evaluation revealed complaints of progressive darkening of skin, weakness and increased fatigability ∗ Corresponding author. E-mail address: sood99@yahoo.com (A. Sood). for past 8 months. Treatment history revealed that the patient was diagnosed recently with hypothyroidism and started on levothy- roxine supplementation from outside. Suspecting the presence of simultaneous uncorrected adrenal insufficiency as the cause, the patient was investigated and found to have severely reduced cortisol and raised ACTH levels. Patient was immediately started with steroid supplements and then evaluated for the underlying cause. Contrast enhanced computed tomography (CECT) of chest and abdomen revealed enlarged bilateral adrenals with associa- ted mediastinal and upper abdominal lymphadenopathy. Positron emission tomography/computed tomography (PET/CT) was per- formed 45 min after administration of 390 MBq of 18 F-FDG for characterization of the lesions and assessment of ideal site for tissue sampling. PET/CT images showed intense 18 F-FDG uptake (SUVmax 24) in the bilateral bulky adrenals and enlarged lymph nodes in the right supraclavicular, mediastinal and upper abdominal regions (Fig. 1). In view of the presence of significant lymphadenopathy, a malignant etiology was suspected. Excision biopsy of the supraclavicular lymph node showed non-specific inflammation. For etiological diagnosis, a laparoscopic adrenal biopsy was performed which revealed large areas of http://dx.doi.org/10.1016/j.remn.2015.11.008 2253-654X/© 2016 Elsevier Espa ˜ na, S.L.U. y SEMNIM. All rights reserved. 2253-8089/© 2016 Elsevier España, S.L.U. and SEMNIM. All rights reserved. © 2016 Elsevier España, S.L.U. and SEMNIM. All rights reserved.