SUN-407 Adrenal Abscess in a Patient with Disseminated Nocardiosis: A Case Report

Abstract Disclosure: A. Miller: None. A. Risbud: None. K.M. Kirkeby: None. D.M. Antoniucci: None. Nocardiosis is a rare, mostly opportunistic bacterial infection that can hematogenously spread to most areas of the body. This case report describes a 57-year-old female with obesity (BMI 33.6), type 2 diabetes (A1c 10.7%), hypothyroidism (TSH 0.69 uIU/mL), end-stage renal disease (status-post 7/2024 renal transplant on prednisone 5 mg daily, tacrolimus, mycophenolate), and hypertension, who developed an adrenal abscess likely from disseminated Nocardia farcinica. She first developed right flank and lower back pain in 12/2024. An outpatient 1/3/25 non-contrast CT abdomen pelvis showed “3.7 cm left adrenal nodular enlargement with mild fat induration” without further workup. Due to ongoing pain and leukocytosis, she was hospitalized for sepsis workup. Her 1/15/25 non-contrast CT abdomen pelvis showed a “4.2 cm left adrenal nodule with surrounding stranding.” When screened for adrenal hormonal hypersecretion, labs were not consistent with pheochromocytoma or hyperaldosteronism (her serum free metanephrine level was only slightly elevated at 98 pg/mL (normal ≤ 57) with normal serum free normetanephrine, total free metanephrine, and aldosterone levels). She had chronic upper lip hirsutism and light abdominal striae from obesity, but couldn’t undergo a full Cushing’s syndrome evaluation due to inpatient stress and being on prednisone for her transplant. Her serum DHEAS level was non-suppressed at 24 ug/dL (normal 15-170) on prednisone and her morning serum cortisol was 14.7 ug/dL (normal 3-16) after holding prednisone for two days. Later on, blood cultures grew N. farcinica and imaging discovered dissemination to the brain, lungs, paraspinal soft tissue (confirmed on fluid cultures), and spleen. Her 1/23/25 abdominal MRI with and without contrast showed a “5 cm left adrenal cystic/necrotic structure with surrounding stranding most consistent with abscess” which was drained on 1/29/25 with cultures pending. This case demonstrates the importance of broadening the differential for adrenal nodules beyond benign, functional, and malignant lesions, especially when the mass is rapidly enlarging and has associated fat stranding as in this immunocompromised patient with a likely N. farcinica abscess. H. capsulatum and M. tuberculosis are more commonly found in adrenal abscesses and 14% of Nocardia isolates in the U.S. belong to the N. farcinica species, so this patient’s presentation is rare. There are also reports of elevated ACTH and ectopic Cushing’s with Nocardia pneumonia [1], which could be relevant here as this patient’s ACTH normalized from 87 pg/mL to 29 pg/mL (normal 6-50) after six days of antimicrobial therapy, though she currently has an incomplete Cushing’s evaluation. [1] Rizwan, A., Sarfaraz, A., Jabbar, A. et al. Case report: Nocardia infection associated with ectopic cushings. BMC Endocr Disord 14, 51 (2014). https://doi.org/10.1186/1472-6823-14-51 Presentation: Sunday, July 13, 2025