RESISTANT HYPERTENSION IN MOOD DISORDERS AND SLEEP DISTURBANCES

Abstract

Objective: A relationship between cardiovascular diseases and psychopathological symptoms has been described in the literature. However, few studies have reported mood disorders in patients with resistant hypertension (RH). We discuss a case of RH in a young otherwise healthy woman, and analyse the diagnostic and therapeutic approach followed.Design and method: A 52-year old woman referred to our Centre for hypertension (170/104 mmHg) uncontrolled by 10 mg/day amlodipine, 10 mg/day ramipril, 25 mg/day hydrochlorothiazide and 4 mg/day doxazozin. The 24h-ABPM showed a Reverse-Dipper profile of BP values (Figure 1). She referred a new onset diabetes, a rapid weight gain and new-onset personality disturbance with generalized anxiety, panic disorder, impairment of memory and asthenia for which she had been treated with sertraline 50 mg and alprazolam 1 mg daiy. She also had insomnia and alteration of dreams which became more bizarre and vivid. Physical examination showed central obesity, supraclavicular fat pads, moon facies with easy bruising and mild hirsutism. Results: Serum cortisol levels at the morning and at the evening and 24h-urinary free cortisol levels were increased (52.7/55.8 mcg/dL and 2450 μg respectively). Hypokalemia (2.6 mEq/L) was also found. A total-body TC scan (Figure 2) revealed a left adrenal gland mass (12 × 13 × 7.5 cm on size) and many nodular focal lesions in the liver suspected as replicating forms. A total body FDG-PET/CT scan (Figure 3) showed an increased uptake of the tracer (SUVmax 5.2) in the left adrenal gland with multiple liver metastases. Despite a therapy with ketoconazole and high doses of mitotane, 45 days after the admission the patient died for a cardio-circulatory arrest but autopsy was not performed by explicit family request. The clinical picture was suggestive for a primary adrenocortical carcinoma (ACC). Conclusions: ACC is a rare and aggressive malignant neoplasm often diagnosed at an advanced stage. The combination of Cushing's syndrome is frequently found, but psychopathological symptoms are rare at the onset of ACC. We suggest not to consider as «depressed» and not to treat with antidepressant agents a young hypertensive subject with resistant HT without having ruled out an organic cause of psychiatric disease.