in june 2010 , a previously healthy 28-year - old male presented with 1 month history of darkening of skin . the patient was well until june 2010 , when his fiance noticed darkening of his face . because of progressive increase in his darkness , she left him . his previous medical history was unremarkable . on examination ; he was afebrile with pulse rate of 82 beats / min , respiratory rate of 16 breaths / min , and blood pressure of 126/78 mmhg without any postural drop . only abnormality in physical examination was generalized hyper pigmentation , which was most marked on face , dorsum of upper limbs , nape of neck , chest and suprascapular region posteriorly [ figure 1 ] . his full blood count , erythrocyte sedimentation rate ( esr ) , glucose , liver , and renal function including electrolytes were normal . an ultrasound abdomen revealed a well - defined hypoechoeic mass in right suprarenal region . computed tomography ( ct ) abdomen showed a well defined , hypo dense mass in right suprarenal gland measuring 23 mm  20 mm without any calcification or intra - abdominal lymphadenopathy . magnetic resonance imaging ( mri ) abdomen revealed a mass measuring 22 mm  24 mm in right suprarenal gland . his adrenal functions were as follow : baseline 8.00 am serum cortisol 160 nmol / l [ normal range 150 - 550 nmol / l ] , increasing to 170 nmol / l 60 minute after 250 g i.v cosyntropin ; [ normal response 550 nmol / l ] . baseline concomitant adrenocorticotropic hormone ( acth ) level was 1100 pg / ml [ normal 9 - 56 ] . on open laparotomy , a right adrenal mass measuring 25 mm  30 mm was detected with superior margin of mass attached to inferior vena cava . standard four drug anti - tubercular ( att ) regimen was started along with hydrocortisone 17.5 mg . fludrocortisone was not started as his blood pressure ( bp ) was normal and his electrolytes were also normal . at 4 week follow up , patient presented with extreme fatigue with loss of energy , severe weakness , tiredness , and postural dizziness . dose of hydrocortisone was increased to 25 mg , fludrocortisone 100 gm was added the patient improved markedly with regard to his constitutional symptoms and his bp was 140/90 mmhg without any postural fall at 2 month follow up . at 6 month , he was well and was on his routine baseline activities . att was discontinued and hydrocortisone dose was reduced to 15 mg and fludrocortisone was also reduced to 50 gm . at last follow up in february 2011 , when asked about his 6 month ordeal journey , he replied :  feeling good because of vanishing tan , but the tan of unfaithfulness will be there forever  . adrenal is involved in 6% of active disease , but it is difficult to establish the diagnosis . the combination of generalized hyper pigmentation with unilateral adrenal mass in the absence of constitutional symptoms was an interesting finding and it illustrates a diagnostic dilemma . tuberculosis was thought to be the cause of adrenal mass , considering the high prevalence of tb in this part of the world , but the unilateral nature of mass was most worrisome , particularly in the absence of active tb and negative tuberculin test . ct of adrenal gland ca nt reliably differentiate between tubercular mass and other benign and malignant mass ; ultimately tissue biopsy remains the mainstay of diagnosis . the initial deterioration in our patient probably resulted from inadequate dose of synthetic cortisol , as rifampicin results in its inactivation . a 2 - 3 fold increase in glucocorticoid dose is required in the presence of hepatic enzyme inducing drug . plasma acth can not be used as a criterion for glucocorticoid dose adjustment . in primary adrenal insufficiency , acth is invariably high before the morning dose and rapidly declines with increasing cortisol levels after glucocorticoid ingestion . aiming at acth levels within the normal range , therefore , would invariably result in over - replacement . in the absence of reliable biomarker of glucocorticoid activity , monitoring of glucocorticoid replacement is primarily based on clinical judgement , carefully taking into account signs and symptoms suggestive of over and/or under replacement .
adrenal tuberculosis is a rare manifestation of active tuberculosis and is a difficult diagnosis to make if its presentation is sole manifestation of tuberculosis . 
 we present an interesting case of a young male who presented only with symptoms of hyper pigmentation and was diagnosed as adrenal tuberculosis . 
 also , this report highlights the importance of drug interaction between antitubercular drug and steroid which lead to the deterioration in the early part of treatment and , later on was corrected by increasing the dose of steroids .