Waterhouse-Friderichsen syndrome Quiz: Ace Your Exams

A 56-year-old male presents to his primary care physician with worsening fatigue, decreasing exercise tolerance and a 15 pound weight loss over the past two months. The patient additionally has a chronic cough, low grade fevers, and cravings for salty foods. He currently lives in Ohio but recently immigrated from Vietnam where he worked as a nurse. He has a history of type II diabetes mellitus and a ten pack year smoking history, but he does not use alcohol or other illicit substances. Temperature is 37.0°C (98.6 °F), pulse is 65/min, respirations are 16/min, blood pressure is 100/72 mmHg, and oxygen saturation is 95% on room air. Physical examination demonstrates a thin, fatigued male in no acute distress with facial hyperpigmentation. A screening PPD test is positive. Which of the following is the most likely etiology of this patient’s clinical presentation?