Abstract
BackgroundPrimary hyperaldosteronism (PA) is a serious and potentially debilitating disease. Detailed guidelines have been written to guide endocrinologists in establishing the diagnosis of PA as well as in subtype classification of PA. The objective of this case report is to present a case where subtype classification of PA was challenging and repeated imaging of the adrenal glands helped establish the diagnosis in a patient with initial normal adrenal glands on CT and MRI images.Case presentationWe report a case of a 29-year-old woman with an established diagnosis of PA, but unclear subtype, who presented to us for further management. She initially presented for medical evaluation of uncontrolled hypertension and spontaneous hypokalemia 4 years prior. In the investigation of secondary causes of hypertension, plasma aldosterone-to-plasma renin activity ratio was elevated on two separate occasions, and primary hyperaldosteronism was confirmed by saline infusion test. Also during this time, she had adrenal venous sampling done 3 times at multiple institutions yielding confusing results. Initially, imaging by CT and MRI showed normal adrenal glands. To help establish the subtype of PA, we reimaged this patient’s adrenal glands one year later revealing a 2 cm left adrenal adenoma. Laparoscopic left adrenalectomy improved her hypertension and was curative of her hypokalemia.ConclusionThis case presents an unusual case where reimaging of the adrenal glands led to the discovery of a single adenoma, initially not observed on imaging studies.
Highlights
Primary hyperaldosteronism (PA) is a serious and potentially debilitating disease
An aldosterone-producing adenoma is an important cause of PA to identify, as surgery would be curative of PA and result in improvement or cure of hypertension and hypokalemia [2,4]
To the best of our knowledge, this is the first reported case where reimaging of the adrenal glands years after initial diagnosis of PA was helpful in identifying an adrenal nodule that was causing PA
Summary
Primary hyperaldosteronism (PA) is due to excess secretion of aldosterone by the adrenal glands. Case presentation The patient is a 29 year-old woman who initially presented to her physician at the age of 25 with uncontrolled hypertension and hypokalemia To control her blood pressure, multiple medications were required, with only minimal effect in establishing blood pressure control. On one of the most recent admissions, we reimaged her adrenal glands (10/17/2011) and found a left adrenal adenoma (2.3 × 1.4 cm, less than 10 Hounsfield units on non-contrast CT images), a finding not previously observed approximately 1 year ago by CT scan and MRI (Figure 1) Considering her history, the authors discussed with her the pros and cons of left adrenalectomy and informed her that this is the likely source of excess aldosterone, though it could not be guaranteed. It has been 9 months since the operation, and at last visit, her blood pressure medications were decreased and one of these two medications will likely be able to be stopped altogether
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