Category: Adrenal Disorders

Monitor: 25


Friday, Apr 26
12:30 PM – 1:00 PM

Objective : To present a case of delayed diagnosis of primary hyperaldosteronism (PA) that was complicated by cardiac arrest.

Methods : N/A

Results : N/A

Discussion :

Case presentation: 51 year-old African American female with a history of recently-diagnosed atrial fibrillation (afib) and uncontrolled hypertension (HTN) was admitted for AICD evaluation after an out-of-hospital cardiac arrest. Admission labs showed severe electrolyte abnormalities:  potassium (K+) 2.1 mmol/L (3.5-5.3 mmol/L), magnesium 1.2 mg/dL (1.5-2.5 mg/dL), and calcium < 5.0 mg/dL (8.6-10.4 mg/dL). Endocrinology was consulted for hypokalemia evaluation. Questioning revealed that 3 months prior to admission she was diagnosed with hypokalemia with K+ of 2.4 mmol/L in setting of losartan and amlodipine. She was subsequently started on K+ supplementation. Two months prior to admission, she developed afib and presented to a local ED where she was found to be hypokalemic at 2.8 mmol/L despite compliance with supplementation. As an outpatient she was placed on sotalol and furosemide by cardiology for treatment of afib and congestive heart failure in the setting of K+ of 3.9mmol/L. Approximately 4 weeks later she experienced a witnessed out of hospital cardiac arrest which lead to her admission. She was empirically placed on spironolactone and hypokalemia stabilized. Endocrine workup of hypokalemia demonstrated: aldosterone (PAC) of 14.8 ng/dL (4-31 ng/dL), renin activity (PRA) 0.2 (0.25-5.82 ng/mL/h), and aldosterone-renin-ratio (ARR) of 74. Labs were repeated as an outpatient while on spironolactone 25mg daily: PAC 47 ng/dL, PRA 0.22, ARR 213. Spironolactone was increased to 50 mg BID and subsequently PRA increased to 5.96 with significant improved blood pressure control. CT imaging did not identify any adrenal nodules. She will have adrenal vein sampling for further evaluation.  

Discussion: PA is thought to occur in > 10% of all hypertensive patients and is often under recognized. PA portends a higher morbidity and mortality when compared to similar patients with essential hypertension. There should be a high index of suspicion especially in patients with resistant hypertension requiring multiple antihypertensives and those who develop spontaneous hypokalemia or diuretic-induced hypokalemia, as was the case with our patient. Hypokalemia is not needed for diagnosis, is relatively uncommon in PA (9-37% of patients), and typically occurs in patients with severe and longstanding disease. Our case highlights the importance of diagnosing PA promptly and the serious complications that can result from a missed diagnosis.

Conclusion : Early and appropriate diagnosis of PA is critical in reducing and preventing adverse cardiovascular outcomes. 


Spandana Brown

Endocrinology Fellow
Houston Methodist Hospital

Dr. Brown is currently a fellow at Houston Methodist Hospital. She completed her undergraduate training at Vanderbilt University and medical school at Baylor College of Medicine. She received her internal medicine training at Houston Methodist Hospital. Her research interests include metabolic bone disorders, obesity and thyroid disease.

Trisha Cubb

Junior Faculty
Houston Methodist Hospital

Dr. Trisha Cubb is currently junior faculty in the department of Endocrinology at Houston Methodist Hospital where she is actively involved in fellowship education. She received her medical degree at the University of Texas Health Science Center Houston and subsequently completed her internal medicine residency at the University of Colorado. She then returned to Houston to complete her Endocrinology fellowship at the Baylor College of Medicine/MD Anderson Cancer Center. She has a particular clinical interest in thyroid disease as well as general endocrinology.

Laila Tabatabai

Assistant Professor of Clinical Medicine; Director, Houston Methodist Endocrinology Fellowship
Houston Methodist Hospital

Laila S. Tabatabai, M.D., is the Program Director of the Houston Methodist Endocrinology Fellowship Program. She is also the Director of the Houston Methodist Hospital Fracture Liaison Service (FLS) and Assistant Professor of Clinical Medicine in the Division of Endocrinology. She received her medical degree, with distinction in research, at Albany Medical College in Albany, New York. Her postdoctoral training included an internship and residency in internal medicine at the University of Maryland Medical Center in Baltimore and a fellowship in endocrinology at Johns Hopkins Hospital in Baltimore.

Steven Petak

Division Chief of Endocrinology, Diabetes and Metabolism
Houston Methodist Hospital

He is a past president of the American Association of Clinical Endocrinologists, the American College of Endocrinology, and the International Society for Clinical Densitometry. He is an associate clinical professor at Weill-Cornell Medical College at the Houston Methodist Hospital and is the division head of endocrinology, diabetes and metabolism as well as service chief of endocrinology. He is a bone densitometry and endocrine consultant to NASA at the Johnson Space Center for about 13 years and has been a part of the bone summit planning long duration space missions. He is the secretary of the board of councilors of the Texas Medical Association (2015) and represents the Harris County Medical Society as vice-councilor.

His awards include Master of the American College of Endocrinology, Yank Coble Public Service Award of the American College of Endocrinology, the ISCD Paul Miller Public Service Award, and ISCD Clinician of the Year. He has authored and co-authored articles, editorials and guidelines in endocrinology and reproductive medicine.

He received his MD from the University of Illinois in Chicago and has his JD from the University of Houston (Magna cum Laude). He had his internship, residency, medical chief residency, and fellowship in endocrinology and metabolism at the University of Texas at Houston. He was at the Texas Institute for Reproductive Medicine and Endocrinology in Houston for about 26 years before joining the academic endocrine group at Methodist in May 2013. He is board certified in internal medicine as well as endocrinology and metabolism. His wife is a veterinarian in private practice and he has 2 children, 4 cats and a dog.