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Case 283

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Female, 30 years old, diagnosed with an 8-year story of persistent hypertension in use of four antihypertensive drugs, is admitted to the hospital due to a Hypertensive Urgency. Laboratorial findings included asymptomatic hypokalemia (K=1,7mEq/L). Other exams were requested: Plasma Aldosterone = 44ng/dL and Plasma Renin Activity = 0,1ng/mL/h, thus revealing an aldosterone-to-renin ratio (ARR) of 440. Primary Aldosteronism (PA) was then diagnosed and further imaging studies were requested.

Analyzing the patient’s story and the given Computer Tomography (CT) images, the most probable etiologic diagnose for this patient’s Primary Aldosteronism (PA) is:

a) Bilateral Adrenal Hyperplasia

25%

b) Aldosterone-Producing Adenoma

25%

c) Adrenocortical Carcinoma

25%

d) Renal Artery Stenosis

25%
   

Image Analysis

Image 1: Abdominal Computed Tomography, axial view at L2 level, after intravenous injection of contrast, venous phase. Round mass (red arrows) with regular shape, well-defined limits, slightly heterogeneous impregnation of contrast, located at right adrenal topography. Dimensions: 3,6 x 3,0 cm. Lesion density before intravenous contrast: 11,5 UH; absolute and relative washouts of 64% and 51%, respectively.

 


Image 2: Abdominal Computed Tomography, coronal view, after injection of contrast, venous phase. Round mass (red arrows) with regular shape, well-defined limits, slightly heterogeneous impregnation of contrast, located at right adrenal topography. Dimensions: 3,6 x 3,0 cm. Lesion density before intravenous contrast: 11,5 UH; absolute and relative washouts of 64% and 51%, respectively.

Relevant aspects

- Primary Aldosteronism (PA) is a frequent cause of Hypertension that is difficult-to-control and not responsive to three classes of drugs (at least one diuretic) or requiring four classes to control;
- PA should be suspected on: patients with spontaneous hypokalemia or induced by diuretics; patients with family history of PA; and patients with adrenal incidentaloma;
- Screening is done by the aldosterone-to-renin ratio (ARR), with attention to interfering factors;
- Hypokalemia is key to the diagnosis: it raises the suspicion of PA and excludes the necessity for confirmatory tests if the ARR is elevated;
- Abdominal CT is extremely important to the etiologic diagnose between the subtypes of PA, once unilateral masses can be surgically removed with great prognosis;
- When bilateral disease is diagnosed, surgical treatment is contraindicated and high doses of aldosterone antagonists need to be used, e.g. spironolactone.

References

- Funder J, Carey R, Mantero F, Murad M, Reincke M, Shibata H et al. The Management of Primary Aldosteronism: Case Detection, Diagnosis, and Treatment: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism. 2016;101(5):1889-1916.

- Herr K, Muglia V, Koff W, Westphalen A. Imaging of the adrenal gland lesions. Radiologia Brasileira. 2014;47(4):228-239.

- Horwich P. Adrenal Adenoma Imaging: Overview, Radiography, Computed Tomography [Internet]. Emedicine.medscape.com. 2017 [cited 3 June 2017]. Available from: http://emedicine.medscape.com/article/376240-overview?pa=U4dbGhKtcv5Q

- Malachias M, Souza W, Plavnik F, Rodrigues C, Borelli F, Gus M et al. 7ª Diretriz Brasileira de Hipertensão Arterial. Arquivos Brasileiros de Cardiologia. 2016;107(3):67-74.

- Wuaifo G. Primary Aldosteronism: Practice Essentials, Pathophysiology, Etiology [Internet]. Emedicine.medscape.com. 2017 [cited 30 May 2017]. Available from: http://emedicine.medscape.com/article/127080-overview

- Young W. Pathophysiology and clinical features of primary aldosteronism [Internet]. Uptodate.com. 2016 [cited 30 May 2017]. Available from: https://www.uptodate.com/contents/pathophysiology-and-clinical-features-of-primary-aldosteronism

Author

Arthur Melgaço, 5th year Medical Student at Federal University of Minas Gerais (UFMG). E-mail: artmelgaco[at]gmail.com

Orientation

Ana Lúcia Cândido, Endocrinologist and Professor of the Intern Medicine Department on the Medicine Faculty on UFMG. E-mail: acandido.med[at]gmail.com

Reviewers

Lucas Bruno Rezende, Rafael Fusaro, Eduardo Paolinelli, Giovanna Vieira, Prof. José Nelson Mendes Vieira and Prof. Viviane Parisotto.

Translation

Arthur Melgaço

Test question

(TRT-RJ: Analyst in Cardiology - 2011) In a case of primary hyperaldosteronism, the most probable findings in blood examination and adrenal histology for POTASSIUM, RENIN, pH and HISTOLOGY are, respectively:

a) increased, decreased, increased, adenoma

25%

b) increased, increased, decreased, carcinoma

25%

c) decreased, increased, decreased, adenoma

25%

d) decreased, decreased, decreased, carcinoma

25%

e) decreased, decreased, increased, adenoma

25%
   

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