PRIMARY ALDOSTERONISM IN YOUNG PATIENT WITH RECURRENT RESISTANT HYPERTENSION AFTER SOLITARY ADRENAL ADENOMA SURGICAL RESECTION

Abstract

Objective: the diagnostic workup of resistant hypertension in young patients the therapeutic approach of patients with primary aldosteronism due to adrenal adenoma and contra-lateral adrenal hyperplasia the diagnostic workup and reevaluation of aldosteronism recurrence after initial surgical treatment the correlation between recurrent resistant hypertension and primary aldosteronism recurrence. Design and method: A 34-year-old male was referred to our specialized department for second-degree arterial hypertension (mean readings 170/110 mmHg). The physical examination was normal, except his 31 kg/m2 Body Mass Index. The ECG and cardiac ultrasound had normal findings. Basic laboratory studies were in physiological range. Secondary hypertension diagnostic workup was decided and initial treatment with two neutral antihypertensive agents. Specific hormonal profile revealed a plasma aldosterone(PA) level of 237.9 pg/ml and a plasma renin activity(PRA) of 0,23ng/ml/h, resulting in a pathological plasma aldosterone/plasma renin activity(PA/PRA) ratio. The saline suppression test revealed a plasma renin activity of 0.02 ng/ml/h and a high plasma aldosterone level of 20,29 pg/ml. The serum levels of dehydroepiandrosterone sulfate, adrenocorticotropin, and cortisol were normal. The suprarenal magnetic resonance imaging illustrated a 46,3 × 31 mm left adrenal adenoma and contralateral adrenal hyperplasia. A surgical intervention was performed with adrenal adenoma enucleation.Results: Postoperatively, the patient remained normotensive for about 14 months. He presented thereafter with a recurrence of resistant hypertension. New basic and hormonal laboratory studies revealed plasma renin activity levels of 0,4 ng/ml/h and plasma aldosterone levels of 381 pg/ml. After saline suppression test, plasma aldosterone levels remained high (163pg/ml). The magnetic resonance imaging illustrated a small left adrenal adenoma of 11 mm and constant right adrenal hyperplasia. The patient was initially treated with 200 mg eplerenone/ day with subsequently dose adjustment to 100 mg/day resulting in mean blood pressure readings of 135/90mmHg and no concurrent hyperkalemia. Conclusions: Primary hyperaldosteronism remains a challenging diagnosis. Unilateral adrenal hyperplasia is statistically rare, as well as the coexistence of contralateral big size adrenal adenoma. In young patients presenting with adrenal adenomas (especially big sized) and concurrent pathological hormonal profile, the surgical treatment is probably required, without however excluding new hormonal control for secondary hypertension in case of hypertension recurrence.