NYU Medical Grand Rounds Clinical Vignette

1. NYU Medical Grand Rounds Clinical Vignette Michael Chu MD, PGY-2 5/20/09

2. Chief Complaint • 71 year old male with difficult to control hypertension for approximately 15 years

3. 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

4. Additional History • Past Medical History: • Hypertension • Type II Diabetes Mellitus • Glaucoma • Diverticulosis • Past Surgical History: • none

5. 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

6. 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

7. Physical Exam • General: Well appearing male in no acute distress • Vital Signs: T:98.7 BP:139/88 HR:62 RR:16 • Trace pedal edema was noted in his lower extremities bilaterally • Otherwise the remainder of his physical exam was normal

8. Laboratory Findings • CBC: Hemoglobin 12.7 g/dLHematocrit 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 > 50 • Ratio > 20 suggestive of primary hyperaldosteronism

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

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

11. 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 > 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

12. 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

13. Final Diagnosis • Primary Hyperaldosteronism