Primary hyperaldosteronism (PA) has an incidence between 5% to 13% as a cause of secondary hypertension. Independent of hypertension, PA itself has demonstrated cardiovascular side effects. Therefore, it may be worthwhile to be aware of any unusual presentations of PA. Our case series shows 2 unique presentations of PA. Cases: A 68-year-old woman with a past medical history of hypertension and hypokalemia had a negative workup for secondary hypertension including PA 10 years ago. She was managed on amiloride however developed a breakthrough with elevated blood pressure (BP), hypokalemia, high serum aldosterone level of 36.6 ng/dl, and low renin of 0.8 ng/ml/hr. CT of the abdomen showed bilateral adrenal hyperplasia (BAH), more prominent on the left side along with a 1.6cm nodule. Adrenal vein sampling (AVS) showed an aldosterone level 3.5 times higher on the left side, but the right adrenal gland aldosterone production was not suppressed. Repeat AVS is now planned. A 63-year-old male with a past medical history of PA in the setting of BAH was treated with an eplerenone-based regimen. During one of his routine nephrology office visits, the patient had potassium of 2.2mmol/L and elevated BP. MRI of the abdomen showed an adenoma of 2 cm on the left adrenal gland. Proper lateralization was documented and underwent left adrenalectomy which proved to be beneficial. Discussion: BAH and unilateral adrenal adenomas account for 90% of PA cases. BAH is medically managed, however, if disease lateralization is noted, surgery may be an option for better long-term BP control. Our first patient had BAH with no documented PA, however, she developed a breakthrough event after several years, and a repeat workup documented a dominant nodule. AVS is still unclear in this patient, and we plan to repeat it. Our second case shows the maturation of one of the adrenal nodules in the setting of well-controlled BAH to produce breakthrough symptoms of PA. Lateralization was documented leading to a successful surgical intervention. A significant improvement in BP and return to normokalaemia was noted clearly exemplifying the role of surgery in BAH.