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Case presentation

Case presentation. By: Dr B atoul Birjandi. Case 1. A 45 -year-old woman sought endocrine assessment after being referred by her physician for HTN and hypokalemia. She had a 4-year history of elevated BP at a rate of 160/100 that was discharged as an outpatient after controlling BP.

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Case presentation

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  1. Case presentation By: DrBatoulBirjandi

  2. Case 1 A 45 -year-old woman sought endocrine assessment after being referred by her physician for HTN and hypokalemia. She had a 4-year history of elevated BP at a rate of 160/100 that was discharged as an outpatient after controlling BP. At recent admission in cardiology department she had a BP of 230/110and hypokalemia (K=1.2). After correction of hypokalemia and control of BP she was referred to this center. The patient mentioned that fatigue and weakness had recently bothering her excessively but she denied any recent weight gain, abdominal pains, headaches, palpitations or chest pain.

  3. PMH: - • DH: Tab losartan 50 mg/bid Tab Amlodipine 5mg/bid • FH: HTN in her mother in 50 YO • P/E: BP: 120/80 PR: 85/min RR: 14/min T: 36.5 • Results of the examination of heart and lungs were unremarkable.The abdominal examination was benign without any striae,HSM or abdominal bruits on auscultation. Extremities examination showed no edema or bruises.

  4. Lab test variable result Na(meq/l) ……………………………. 143 K(meq/l) …………………………….. 3 FBS(mg/dl)……………………………. 119 BUN(mg/dl)…………………………… 15 Cr(mg/dl) ………………………………. 1.3 Aldosterone(ng/dl) ………………… 29.5 PRA(ng/ml/h) ………………………… 0.11 ARR= 290

  5. PRIMARY ALDOSTERONISM SUBTYPE

  6. Adrenal CT Size:15.3 *14mm -10 H Well diffined

  7. C l i n i c a l P r a c t i c e G u i d e l i n e 2016

  8. Silvia Monticone et al.LancetDiabetes Endocrinol2017 • 31 studies including 3838 patients with primary aldosteronism and 9284 patients with essential hypertension. • median Follow up of 8·8 years

  9. follow-up • patients were invited for follow-up visits at 1 month and then 6–12 months following surgery. • This time period was chosen because the full benefit of adrenalectomy – taking into account the gradual decrease in medication – is obtained after 6 months. • BP outcome was classified into three categories recommended by AHA for the assessment of BP outcome associated with renovascular disease: • hypertension cure :systolic BP (SBP) of <140mmHg and diastolic BP of less than 90mmHg for patients offantihypertensive medication(44%) • improvement: either SBP of <140mmHg or diastolic BP <90mmHg or both, or a 15mmHg or greater reduction in diastolic BP for patients remaining on the same or less medication(90-100%) • failure: either as no change in BP or patients not fulfilling the criteria for cure or improvement. • Benefit is defined by either cure or improvement Letavernier E et al. J Hypertens. 2008 Sep;26(9):1816-23

  10. Case 2 • A 65-year-old man with a history of hypertension was admitted to our hospital  for the evaluation of high blood pressure. He had been diagnosed with hypertension at 17 years ago . His blood pressure had been well controlled with 2 drugs for 13 years but from 4 years ago he have had uncontrolled BP on multi antihypertensive drugs. • PMH: DM+( from 25 y ago) /HLP+/ HTN+/ Retinopathy+/ Nephropathy+ /Neuropathy+ • FH:+ ( but controlled by fewer drugs) • SH : smoker+ addict+

  11. DH: -Tab HCTZ 25mg/bid - TAB Carvedilol 3.125mg/bid -Tab valsartan 160mg/bid -Tab Aldactone 25mg/d -Tab Amlodipine 5mg/d -Tab terazosin 5mg/bid -Tab minoxidil 2.5 mg/bid Tab metformin 500mg/tds NPH Insulin (30…….6) RegInsuli (6…….6) Tab ASA 80mg/d Tab Atorvastatin 20mg/d

  12. P/E • BP:180/100……..150/90 PR:88/min RR:16 T:36.5 BMI: 34.5 • Orthostasischanges,negative • Abdomen,no bruit • Muscle force :5/5 • Pitting edema 2+

  13. CBC:NL • FBS:123 • BUN:18.4 • Cr:1.1 • Uric Acid:4.2 • TG:62 • HDL:63 Abdominopelvicsono: NL

  14. Adrenal CTA 15*14mm <10 H

  15. Adrenal CT 14*17.8mm <10 H

  16. Lab Test • CBC:NL • Na:140 • K:3.8 • BUN:22 • Cr:1.5(GFR:48) • Hb A1C: 5.5 • U/A: Pr +++ Aldosterone=19.3 ng/dl Renin=2.9micg/ml

  17. Serum Aldosterone:15.4 ng/dl PRA: 0.44 ng/ml/h ARR:34 • The patient was treated with the following antihypertensive drugs for one month: -Tab diltiazem120mg/bid - Tab hydralazine 50mg/Tds -Tab prazosin 5mg/Tds

  18. Case Confirmation: • Four testing procedures: (No gold standard) • Oral sodium loading test • Saline infusion test (SIT) • Fludrocortisone suppression test • Captopril challenge test *Choice: cost, compliance, lab routine, local expertise

  19. SIT • Lack powerful study designs for establishing the test accuracy • Sensitivity: 83-88% • Specificity: 75-100% Post infusion plasma Aldosterone: <5 ng/dl..………unlikely 5-10………intermediate >10…….very probable 2007 J Hypertens 25:1433-42

  20. Our case SIT Start End PAC (ng/dL) 16 13.5 15.4(2h) Renin (µIU/ml) 7.6 10.3 Cortisol (µg/dL) 13.1 11.9 Potassium (mEq/L) 4.6 4.8 PAC/Cortisol 1.22 1.13

  21. Ald/Cortisol Ratio Measurement of post SIT Serum Ald /Cortisollevel [ if > 3 (ng/dl / µg/dl), differentiates between APA and IHA (P = 0.001) ] Journal of Hypertension 2006, 24:737–745

  22. patients with PA and a typicalConn’sadenoma of at least 8 mm on CT scan can beconsideredas having unilateral aldosterone hypersecretionif they also have serum potassium less than 3.5 mmol/ liter(regardless of the prescription of potassium supplements) and/or eGFR of at least 100 ml/min/1.73m2. If this rule is validated, as much as 30% of PA patients could avoid AVS and be directly diagnosed with unilateral PA. The lowest threshold 5 Subjects with a score of at least 5 were those with a typical Conn’s adenoma plus serum potassium less than 3.5 mmol/liter or eGFR of at least 100 ml/min/1.73 m2 (or both). This criterion had a specificityof100%(95%CI, 91–100) and a sensitivity of53%(95% CI, 38–68) to predict a lateralized Our patient=3 Elselien M. Ku¨ pers et al. J clinEndorcinolMetab 2012

  23. Unsuccessful or unavailable AVS: • Repeat AVS • Treat with MR antagonist • Consider surgery based on the other studies: • Adrenal CT Scan • Posture Stimulation Test • Morning Recumbent 18-OHB levels • The absence of the significant increase (<30%) of PAC at the upright posture supports the diagnosis of APA • Test accuracy: 85% • Fontes RG, Am J Hypertens1991;4:786-9 Young WF, EndocrinolMetabClin North Am 1988;17:367-95 • The fall in PAC during 4 h erect posture has PPV of 100% for diagnosis of unilateral lesion • EspinerEA, J ClinEndocrinolMetab 2003;88:3637-44

  24. Predictors of persistent hypertension after adrenalectomy include: • older age • family history with more than one first-degree relative with hypertension • use of more than two antihypertensive drugs preoperatively • duration of hypertension of more than 5 years • concomitant essential hypertension • large gland size at operation • increased serum creatinine levels and coexistence of other forms of secondary hypertension. • reduction in mean BP of 15 mmHg or more after 10 days of spironolactone therapy, 100 mg/d, suggests a strong likelihood of post-operative cure of hypertension AsteriosKaragiannis et al. Endocrine-Related Cancer (2008) 15 693–700

  25. Alternatives to adrenalectomyMineralocorticoid receptor antagonists – spironolactone and eplerenone - provide a specific treatment for PA in patients who are not candidates for surgery. • Unfortunately, only a few of these patients show a good BP response to spironolactone monotherapy. Furthermore, long-term tolerance of spironolactone at doses exceeding 50 mg per day is poor. • There is no published evidence to suggest that high doses of eplerenoneare more effective and better tolerated than spironolactone in patients with PA. If necessary, lower doses of aldosterone receptor antagonists may be associated with non specific antihypertensive agent. Amar et al. Orphanet Journal of Rare Diseases 2010, 5:9

  26. BP:155/66 PR:67 • Tab Aldactone 50mg/bid • Tab hydralazine 50mg/TDS • Tab Diltiazem 60 mg/TDs • Tab Prazosin 5mg/ TDS

  27. Case 3 • A 64 -year-old female with an 2 month history of hypertension presented at our hospital. She wasknown case of colon adenocarcinoma with total colectomy and chemotherapy (12 se) in 4 year ago. • She has been followed annually with AP CT scan for her cancer. • In the last CT scan in the past 2 month ,the incidentaloma has been seen (at the same time with HTN detection) . • PMH: Appendectomy in 62/ hysterectomy 1n 92/ total colectomy in 92 • FH: Breast cancer (sister)/ HTN (mother)

  28. DH: -Tab ditiazem 120 mg/bid -Tab prazosin1mg/bid P/E: BP: 175/100……..120/80 PR:80 RR:14 T:37 Abdominal scar+

  29. Lab test: • CBC:NL 24 h urine collection: V:850 cc • BUN:14 Cr:995mg/d • Cr:0.9 MN:89.6mcg/d • Na:141 NMN:90 • K:4.1 • Aldosterone:9.1 ng/dl • PRA:0.11ng/ml/h ARR:90

  30. Our case SIT Start End PAC (ng/dL) 19.7 6.5 9.1(2h) Renin (µIU/ml) 1.7 3.9 PRA (ng/ml/h) 0.36 2.86 Cortisol (µg/dL) 21.5 3.3 Potassium (mEq/L) 3.7 4.1 PAC/Cortisol 0.91 1.9

  31. Ald/Cortisol Ratio Measurement of post SIT Serum Ald /Cortisollevel [ if > 3 (ng/dl / µg/dl), differentiates between APA and IHA (P = 0.001) ] Journal of Hypertension 2006, 24:737–745

  32. CPS:3

  33. BP: 120/80 PR:80 Tab ditiazem 120 mg/bid Tab prazosin1mg/bid

  34. PanagiotaEconomopoulou et al.Case Reports in Medicine. Volume 2013(2013)

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