Adrenal Disorders
Kelara Samuel, MD
Resident Physician
University of South Florida
Tampa, Florida, United States
The classic presenting signs of primary aldosteronism are hypertension and hypokalemia, which is often underdiagnosed in patients with hypertension. If the biochemical workup is not done in an adequate setting, it can lead to a delay or a missed diagnosis.
Case(s) Description :
A 26-year-old female with a past medical history of anemia, Chiari malformation type I, GERD, hypothyroidism, and severe hypokalemia and hypertension for two years requiring multiple visits to the Emergency Department, presents for ongoing symptoms of nausea and abdominal pain. Her potassium levels ranged between 2.3 to 2.7 mEq/L requiring high dosages of potassium supplementation that she was tolerating partially due to nausea. After multiple presentations to the hospital without improvement in her symptoms, she was referred to Endocrinology. Her initial workup for primary hyperaldosteronism, which was done in the Emergency Department, showed plasma renin activity (PRA) 0.39 ng/ml/h, aldosterone (PAC) 8 ng/dL, and potassium level 2.5 mEq/ L. At the time, she was told that it was unlikely for an endocrinopathy to be contributing to her symptoms. Repeat levels were ordered and showed PRA 1.04 ng/ml/h, PAC 33 ng/dL, potassium level 3.4 mEq/ L, and PAC/PRA ratio calculated to be 33. A CT scan with adrenal protocol showed a 1.3 cm right adrenal gland nodule that measured 9 Hounsfield units. The absolute and relative washouts measured 60.3 and 56 percent. Interventional Radiology was consulted for adrenal venous sampling, which showed a right adrenal PAC/ cortisol of 85 and left adrenal PAC/cortisol of 1.31, suggestive of lateralization to the right adrenal and unilateral disease. The patient then underwent a robotic right adrenalectomy. Post-operatively, she remained with hypokalemia and high blood pressure for one week, which slowly improved until normalization. The patient is currently off anti-hypertensive medications and potassium supplementation.
Discussion :
We present a unique case of primary hyperaldosteronism that was initially ruled out due to falsely normal PAC levels during periods of hypokalemia. This case illustrates the importance of considering primary hyperaldosteronism in the setting of uncontrolled hypertension and hypokalemia and considering confounding factors in the initial testing. Additionally, we note the prolonged improvement of hypertension and hypokalemia post-operatively, which we attribute to be due to delays in diagnosis.