Intermittent hyperaldosteronism. Is this an entity?

Program: Abstracts - Orals, Featured Poster Presentations, and Posters
Session: SAT 53-73-Primary Aldosteronism & Mineralocorticoid Excess
Clinical
Saturday, June 15, 2013: 1:45 PM-3:45 PM
Expo Halls ABC (Moscone Center)

Poster Board SAT-67
Rajeev Sharma*1, Jocelyne Georges Karam2 and Elizabeth Sedlis Singer2
1SUNY Downstate Medical Center, Brooklyn, NY, 2Maimonides Medical Center, Brooklyn, NY
Background: Primary hyperaldosteronism is a known but commonly overlooked cause of hypertension in general population. Herein, we describe a case with atypical presentation, so called intermittent hyperaldosteronism.

Case report: 25 year-old Chinese man with no medical history was admitted with generalized muscle weakness and fatigue of few weeks duration. On presentation, BP was 160/104, and pulse 74. History was negative for polyuria, vomiting or diarrhea. No use of diuretics, liquorice, excessive soda, laxatives or OTC’s. Laboratory tests showed K 1.8 mEq/L, Na 142, Cl 98, HCO3- 32, Mg 2.1, normal renal and thyroid functions. Urinary K+ was 22 mmol/L.  EKG showed U waves in lateral leads. Potassium was replaced aggressively. CT abdomen showed 1.5 cm enhancing right adrenal nodule. Renin/aldosterone was sent on two occasions before and after K replacement. Overnight 1 mg dexamethasone suppression test and plasma metanephrines were normal. Patient was discharged with K tablets, hydralazine and verapamil. The initial aldosterone level was 5 ng/dL with plasma renin 0.08 ng/ml/hr and ARR 62 (Serum K 3.4). Repeat aldosterone level after K replacement (K- 4.4) was 4 ng/dL. Patient did not fulfill the diagnostic criteria of primary hyperaldosteronism (both aldosterone>15 and ARR>20) and was lost to follow up.

Three months later, the patient returned to the ED with dizziness, pre-syncope and weakness. He reported not taking his medications.  BP was elevated (152/103) and serum K 2.8 mEq/L. Random urinary K was 69. Serum aldosterone was 35 and plasma renin 0.14 with ARR 250 (Serum K- 3.1).  An IV saline suppression test failed to suppress the aldosterone (Serum K- 4.2; Aldosterone: pre-test-34, post-test-30; Renin: pre-test- 0.12, post-test- 0.06). He was diagnosed with primary hyperaldosteronism and discharged on only spironolactone 25 mg daily. One week later in the clinic his serum K was 4.4 mEq/L and BP 130/90. He was referred to the surgeon for right adrenalectomy.

Conclusion: As per our literature search, this is the first reported case of intermittent hyperaldosteronism in an adult patient; there is only one published case of a pediatric patient with this entity. (1) In patients with clinical, radiological and laboratory features suggestive of hyperaldosteronism a repeat aldosterone/renin levels might be warranted due to possible intermittent secretion of aldosterone from the adrenal adenoma.

Reference:

  1. Rogoff D, Bergada I, Venara M, Chemes H, Heinrich JJ, Barontini M. Intermittent hyperaldosteronism in a child due to an adrenal adenoma. Eur J Pediatr. 2001; 160(2): 114-6.

Nothing to Disclose: RS, JGK, ES

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