Abstract: PUB251
Primary Aldosteronism with Hypercortisolism in a 47-Year-Old Man
Session Information
Category: Fluid, Electrolytes, and Acid-Base Disorders
- 1102 Fluid, Electrolyte, and Acid-Base Disorders: Clinical
Authors
- Mosulishvili, Tamar, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, United States
- Ofri, Dylan M., Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, United States
- Hopley, Charles Wilfley, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, United States
Introduction
Despite its high prevalence, PA remains underdiagnosed and undertreated. There is a need for clinicians to be well-versed in additional features that PA can present with, to initiate appropriate and timely diagnostic workup.
Case Description
A 47-year-old man with extensive CV history, including persistent HTN (on several medications) and hypokalemia, presented with diaphoresis, lethargy, nausea, abdominal cramps, and muscle aches. Chart review revealed multiple admissions with HTN and hypokalemia. On admission, he was mildly ill-appearing, VSS and WNL, Weight 121.9kg, BMI 37. PE: unremarbakle with negative Cushingoid signs. Labs notable for K 2.5, Cl 83, HCO3- 36, AG 16. BUN 37 with creatinine 1.57. Glucose was 326, with Hgb A1c at 14.3%. A CT abdomen showed a 12mm left adrenal nodule. Empirical treatment for PA was initiated with potassium, IV fluids and insulin. Aldosterone was 16ng/dl and renin activity was 1.3ng/ml/hr. Adrenal venous sampling revealed unilateral left aldosterone hypersecretion with cortisol-corrected aldosterone ratio > 4 at 17, further supported by non-dominant adrenal vein cortisol corrected aldosterone (0.4) to IVC (2.3) (R/IVC) ratio of less than one at 0.17. Notably, left adrenal gland cortisol was significantly higher at 1117 (right at 172), suggestive of adrenal adenoma producing concomitant high levels of cortisol and aldosterone. The shared decision for left laparoscopic adrenalectomy was made.
Discussion
This case demonstrates an interesting and rare presentation of primary aldosteronism with additional features. Since laparoscopic adrenalectomy can be curative for unilateral adenomas, adrenal venous sampling to determine lateralization is recommended. In the case of this patient, secondary hyperaldosteronism and hypertension likely due to primary hyperaldosteronism with elevated cortisol levels are potentially suggestive of aldosterone and cortisol co-producing adenoma (A/CPA). About 10% of patients with PA also have A/CPA, and in patients with PA and single adenoma, the prevalence of A/CPA is 9.7 – 20%. Patients with A/CPA are more prone to metabolic abnormalities and have higher risk of cardiovascular events. Characterization of A/CPAs prior to surgery is critical since the removal of A/CPAs can result in post-op adrenal crisis and required management with hydrocortisone replacement therapy.