Category: Adrenal Disorders

MALIGNANT HYPERTENSION: A CLINICAL PRESENTATION OF PRIMARY ALDOSTERONISM

Monday, Apr 8
1:00 AM – 2:00 AM

Objective :

Primary aldosteronism is the most common cause of secondary hypertension and should not be overlooked as it is related to higher rates of prior stroke compared to primary hypertension.


Methods : N/A


Results :

A 41 year old woman with history of untreated hypertension presented to the emergency department with right hemiparesis and dysarthria. Blood pressure was 216/120.  Physical exam was notable for right facial droop, right distal upper extremity weakness, and dysarthria.  Labs revealed serum potassium of 2.9 mg/dL. Computed tomography angiography of head and neck showed a left basal ganglia intracranial hemorrhage. 

Given finding of malignant hypertension associated with hypokalemia, secondary causes for hypertension were explored. Additional workup revealed morning plasma aldosterone concentration (PAC) of 33 ng/dL and plasma renin activity (PRA) of 0.16 ng/mL/hr.  These findings were highly suggestive of primary aldosteronism. The patient was discharged on four anti-hypertensives with improvement in blood pressure while awaiting outpatient confirmatory testing for primary aldosteronism.


Discussion :

Patients with primary aldosteronism have a higher prevalence of cardiovascular morbidity and mortality such as stroke compared to patients with essential hypertension. Guidelines from Endocrine Society recommend screening for primary aldosteronism in patients with hypertension and hypokalemia that is either spontaneous or related to low-dose diuretic use. Initial testing begins with measurement of plasma aldosterone concentration and plasma renin activity. Although a high PAC > 20 ng/dL and a low PRA < 1 ng/mL/hr are suggestive of primary aldosteronism, the diagnosis of primary aldosteronism must be confirmed by demonstrating inappropriate aldosterone secretion with one of several tests (ie, saline challenge, oral sodium loading, fludrocortisones suppression or captopril challenge test).


Once a diagnosis of primary aldosteronism is confirmed, the patient should undergo further testing to distinguish between primary aldosteronism due to unilateral aldosterone-producing adenoma or bilateral adrenal hyperplasia. This is an important distinction since management differs between the two, with mineralocorticoid receptor antagonists in bilateral and minimal invasive adrenal surgery in unilateral disease. 


Conclusion : Primary aldosteronism should be considered in patients presenting with malignant hypertension. Because of the higher rates of cardiovascular morbidity and mortality such as stroke in patients with primary aldosteronism compared to patients with essential hypertension, early diagnosis and management are important for primary and secondary prevention of stroke in this patient population.

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Chih-Han Lee

Internal Medicine Resident
California Pacific Medical Center, California

Chih-Han Lee is a second year Internal Medicine resident at the California Pacific Medical Center.

Leonierose Dacuycuy

Endocrinology Fellow
California Pacific Medical Center

Dr. Leonierose Dacuycuy is currently a first year Endocrinology fellow at the California Pacific Medical Center.

Anthony Yin

Associate Program Director, Dvision of Endocrinology
California Pacific Medical Center

Dr. Yin is a graduate of Saint Louis University School of Medicine. He completed his internship and residency in internal medicine at Dartmouth-Hitchcock Medical Center before completing his fellowship in endocrinology at Los Angeles County Harbor-UCLA Medical Center. His clinical interests include neck ultrasonography, fine needle aspiration biopsy of thyroid nodules, cervical lymph nodes and suspected parathyroid adenoma, treatment of thyroid cancer, and male andrology. He serves on the medical staff at both California Pacific Medical Center as well as Novato Community Hospital.