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Case Presentation

This case presentation outlines the diagnostic challenges faced in managing uncontrolled hypertension in a 55-year-old woman with a history of primary aldosteronism and left adrenalectomy. The patient's workup, imaging studies, surgery report, and treatment outcomes are discussed.

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Case Presentation

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  1. Case Presentation By: DrRezvankhah.B DrZabandan.N February 6th, 2017

  2. Patient’s Identification 55 year old woman, Married, Born in Tehran, living in Tehran ,

  3. Chief Complaint • Uncontrolled Hypertension (referred to our clinic by nephrologist for further W/U)

  4. Present Illness • The patient was a 55 year-old woman Known Case of Primary Aldosteronism,had been underwent left adrenalectomy 6 years ago,referred to our clinic with chief complaint of uncontrolled HTN (SBP=220 mmHg) since 95/02 despite on anti HTN medication with valsartan 160 mg, BID, Aldacton25 mg, daily and Metoral 25 mg BID. She did not experience headache, flushing, palpitation or sweating nor numbness or tingling.

  5. Fatigue(-) Weight loss(-) Weight gain(-) Polyuria(-) Hirsutism(-) Easy Bruising(-) Muscle Weakness(-)

  6. History • The patient states that she has had HTN since 1378 which was uncontrolled even with full dose three medication antihypertensive treatment. Following an accelerated episode in 1388 she was admitted to hospital and worked up for secondary HTN.

  7. Following cardiologist’s consult with nephrologist due to accelerated uncontrolled HTN, the following work ups were ordered for the patient: • Urine 24hr 2 times fro evaluation of metanephrine, normetanephrine and VMA • Check plasma renin activity and Aldosteron level • Abdomino-pelvic CT scan with contrast to evaluate adrenals

  8. Continue • Metanephrine, normetanephrine and VMA levels were normal both times due to medical records (values not available). • On 1388/07/20 • Aldosteron: 391 pg/ml Renin: 2 • Aldosteron: 121 ng/ml.hr Renin:0.04 *at this time patient’s HTN was being managed using Diltiazem 120 mg, BID/ Spironolacton 25mg, daily and Valsartan 160 mg, BID *It is not clear which values are before and which are after receiving saline serum.

  9. Imaging studies of the patient on 1389 • Adrenal Gland Sonography 1388/06: a 19*15 mm cyst in left supra-renal region that could be related to adrenal gland. • Spiral CT of Abdomen and Pelvic 1388/06: enhanced solid mass 15*10 mm in right and one solid cystic mass 21*15 mm in left adrenal glands are seen. Bilateral Pheochromocytoma or adenomas are suggested.

  10. At this point, lab data and imaging were suggestive of primary hyperaldosteronism due to bilateral hyperplasia and follow up of the patient and medical management of the HTN was planned.

  11. Patient’s f/u in 10 months • Abdominal MRI 1389/04:18*16 mm cystic lesion in left adrenal gland without enhancement. No lesion in right abdominal gland. No abnormal enhancement. • Plasma Renin Activity: 20.72 ng/mL upright: 1.5-5.7 • Aldosterone: 140 pg/mL upright: 25-315

  12. Surgery Report (1389/05/31), Labafinejad Hospital Pathology Report of the adrenal mass: • Laparoscopic Adrenalectomy of the left Adrenal mass • Adrenocortical adenoma in the background macronodular hyperplasia

  13. 2 months after the surgery (1389/07/18) • BP=165/95 • Aldosterone: 290 pg/ml (30-273) • Renin: 1.4 ng/ml.hr(4.4-46) • Under treatment with Amlodipine 5 mg, BID/ Metoral 50 mg, BID/ Spironolacton 25 mg, daily

  14. F/U from 1389-1395 • Patient’s BP was nearly controlled from 120/80 to 150/80 mmHg. Electrolytes and U/A were normal during this period. • Patient was receiving Valsartan 160 mg, BID/ Spironolacton 25 mg, daily and Metoral 50 mg BID • Following a grief,she found out BP control was disrupted. • Patient was advised to stop spironolactone and substitute it with diltiazem to take the following lab tests which she forgot to do so…

  15. Continue… • PMH:primary aldosteronism +, HTN+, DM-, IHD- • PSH: laparascopicadenomectomy of left adrenal • HH: Negative • DH: Valsartan 160 mg,BID/ Metoral 25 mg, BID/ Aldactone 25 mg daily

  16. Physical Examination • An average normal looking woman for her age • Wt:85 Ht:164 BMI:30 • BP: Upright: 150/90 mmHg Supine: 170/90 mmHg • PR: Upright: 92/min Supine: 84/min • Head and neck: no moon face, no LAP, normal thyroid • Chest: NL lung and heart examination • Abdomen: no organomegalies, no sterias,

  17. Continue… • Extremities: decreased upper and lower proximal muscle forces= 4/5, Nl distal muscle forces • Nl neurologic examination of extremities • Nl pulses in extremities • 1+ equal pitting edema was detected on both lower extremities down to knee • No stigmata of Cushing syndrome

  18. Right after re-experiencing of uncontrolled BP, Masood Laboratory, 1395/02/25

  19. Lab data 1395/11/03

  20. MRI, 1395/02/21 • A 14 mm adenoma in left adrenal and a 19 mm adenoma in right adrenal

  21. Problem list • 55 year old woman • Hx of primary aldosteronism& left adrenalectomy • Recently uncontrolled HTN • PAC/PRA: 112 • Imaging data of bilateral adrenal lesions

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