Category: Adrenal Disorders
Objective : To present a case of primary hyperaldosteronism (PHA) caused by unilateral adrenal hyperplasia (UAH) in a patient with severe hypertension (HT).
Methods : The clinical or paraclinical characteristics of the patient are presented.
Results : Woman, 70 years old, HT resistant for 40 years which is partially controlled with Irbersartan 150mg bid, Nifedipine 30mg bid, Methyldopa 250mg tid and Spironolactone 25mg qd. 2 years ago during stress test she presented a hypertensive emergency reason for which she was hospitalized in the cardiology service being diagnosed of myocardial ischemia, SVPT, AF and sinus node dysfunction, so she was placed on a bicameral pacemaker and was prescribed Bisoprolol 5mg qd and Propafenone 150mg qd. During this hospitalization he presented episodes of hypokalemia (2.9mmol/L) which was corrected with IV administration of potassium. 1 year ago he presented an episode of muscle weakness and paresthesias in the lower limbs, so he went to the emergency room to find a hypertensive crisis associated with hypokalemia (2.6mmol/L). An adrenal CT was performed where a dependent image of left adrenal gland compatible with an adenoma is visualized. She was hospitalized in Endocrinology where the baseline values obtained after potassium normalization and modification of antihypertensive therapy without ARB2 and spironolactone were: Aldosterone: 45.4ng/dl (VN: 2.94-16.1); ARP: 0.4ng/ml/h with a ARR: 113.5. Given that ARR> 20, a confirmatory test with captopril test was performed, obtaining values of Aldo 34.4 ng/dl (24% reduction) and ARP: 0.2 ng/ml/h (value persists suppressed) confirming the diagnosis of PHA. She underwent adrenal venous catheterization with the following results: Aldo/cortisol IVC ratio: 4.84; in LSV: 12.18; RSV: 0.48, finding a relationship between LSV/RSV of 25.15, confirming lateralization coinciding with CT. The patient underwent left laparoscopic adrenalectomy which resulted in multifocal nodular cortical adrenal hyperplasia. At 6 months postoperatively the patient denies discomfort and presents normal BP values with Irbersartan 150 mg qd with normal Aldosterone values (13.2ng/dl), non-suppressed ARP (3.4 ng/ml/h) and normokalemia.
With the presented case we wish to emphasize the importance of an adequate diagnostic approach in patients with secondary and/or severe HT; highlight the importance of adrenal venous sampling for aldosterone in the decision of therapeutic behaviors and especially the role of unilateral adrenalectomy in patients with UAH despite the scarce evidence in the world literature.
Conclusion : UAH as a cause of hyperaldosteronism is infrequent and its resection allows significant control or even the cure of HT
HOSPITAL NACIONAL EDGARDO REBAGLIATI - UNIVERSIDAD NACIONAL MAYOR DE SAN MARCOS. LIMA - PERU
Lima, Lima, Peru
PERUVIAN ENDOCRINOLOGIST, UNIVERSITY TEACHER, ACTIVE MEMBER OF AACE, AREAS OF INTEREST NEUROENDOCRINOLOGY, THYROID, ENDOCRINOLOGY OF REPRODUCTION AND BONE MINERAL METABOLISM