NYU Medical Grand Rounds Clinical Vignette

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NYU Medical Grand Rounds Clinical Vignette

• Michael Chu MD, PGY-2
• 5/20/09

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Chief Complaint

• 71 year old male with difficult to control
  hypertension for approximately 15 years

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History of Present Illness

• The patient was noted by his primary care
  physician to have difficult to control
  hypertension despite being treated with five
  antihypertensive medications
• The patient was largely asymptomatic
• Noted to require potassium supplementation to
  maintain normal potassium levels

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Additional History

• Past Medical History
• Hypertension
• Type II Diabetes Mellitus
• Glaucoma
• Diverticulosis
• Past Surgical History
• none

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Additional History

• Social History
• Previous tobacco use, quit 10-15 years prior
• 1-2 drinks of alcohol 3-4 times per week
• Works as a plumber and owns business
• Family History
• No history of heart disease or diabetes in the
  family
• Sister died of a brain tumor in her 70s

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Medications

• Allergies
• Lisinopril (lip swelling)
• Medications
• Aspirin 325mg PO daily
• Atenolol 50mg PO daily
• Chlorthalidone 25mg PO daily
• Hydralazine 50mg PO BID
• Losartan 50mg PO BID
• Nifedipine 90mg PO daily
• Potassium Chloride 40 meq PO BID
• Simvistatin 20mg PO daily
• Metformin 1000mg PO BID
• Timolol eye drops

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Physical Exam

• General Well appearing male in no acute distress
• Vital Signs T98.7 BP139/88 HR62 RR16
• Trace pedal edema was noted in his lower
  extremities bilaterally
• Otherwise the remainder of his physical exam was
  normal

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Laboratory Findings

• CBC Hemoglobin 12.7 g/dL Hematocrit 37.1
• Remainder of the CBC was within normal limits
• Basic Metabolic panel Potassium 3.4 mEq/L,
  previously had been as low as 3.0 mEq/L
• Remainder of the BMP was within normal limits
• Hepatic panel within normal limits
• Aldosterone level 10.9 ng/dL (Ref. range 1.0-16)
• Plasma Renin Activity 0.2 ng/mL/hr (Ref. range
  0.3-3)
• Aldosterone/Renin ratio elevated gt 50
• Ratio gt 20 suggestive of primary
  hyperaldosteronism

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Imaging

• Magnetic Resonance Imaging of the Abdomen
  revealed an 8 millimeter adenoma of the left
  adrenal gland and no evidence of renal artery
  stenosis

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Differential Diagnosis

• Hyperfunctioning adenoma, such as a
  pheochromocytoma or aldosterone secreting tumor
• Non-functioning adenoma
• Bilateral adrenal hyperplasia
• Adrenal cancer
• Metastatic cancer
• Myelolipoma

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Clinic Course

• The patient was referred to the endocrinology
  clinic for further management and repeat lab
  testing was performed
• Aldosterone level 28.3 ng/dL
• Plasma Renin Activity level 0.48 ng/mL/hr
• Aldosterone/Renin ratio elevated gt 50
• 24 hour urine catecholamine and metanephrines was
  within normal limits
• Salt loading testing was performed and serum
  aldosterone level was noted to be non-suppressed

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Clinic Course

• It was recommended for the patient to undergo
  adrenal vein sampling to differentiate between an
  aldosterone secreting adenoma and bilateral
  adrenal hyperplasia, however the patient opted
  for medical management
• The patient was started on spironolactone therapy
• Since beginning spironolactone, the was able to
  come off of Chlorthalidone, Hydralazine and
  potassium supplementation

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Final Diagnosis

• Primary Hyperaldosteronism