Systemic hormonal unloading in unilateral adrenalectomy in a patient with bilateral adrenal hyperplasia: A case report
10.35460/2546-1621.2018-0055
- Author:
Ma. Felisse Carmen GOMEZ
1
;
Florence Rochelle GAN
2
;
Erick MENDOZA
3
;
Leilani B MERCADO-ASIS
4
Author Information
1. University of Santo Tomas Hospital, Internal Medicine - Section of Endocrinology and Metabolism
2. University of Santo Tomas Hospital, Section of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine
3. Department of Internal Medicine and Endocrinology, University of Santo Tomas
4. Faculty of Medicine and Surgery, University of Santo Tomas
- Publication Type:Case Reports
- Keywords:
Hormonal unloading;
Primary aldosteronism;
Bilateral adrenal hyperplasia;
Case report
- MeSH:
Hypertension;
Hyperaldosteronism
- From:
Journal of Medicine University of Santo Tomas
2019;3(1):303-308
- CountryPhilippines
- Language:English
-
Abstract:
Background :Unilateral adrenalectomy has not
been recommended in the guidelines as a treatment
for primary hyperaldosteronism secondary to bilateral adrenal hyperplasia (BAH). Interestingly, recent
studies have shown that increased circulation of
aldosterone increased oxidative stress, cardiovascular (CV) complications such as atrial fi brillation,
myocardial infarction and heart failure; and that unilateral adrenalectomy led to improved CV function.
Therefore, recognizing the role of unilateral adrenalectomy in BAH, specifi cally for improved quality of
life is important.
Clinical case: A 47‐year-old hypertensive (highest
blood pressure [BP] 150/90 mmHg) woman had a
severe headache, muscle weakness, polyuria, and polydipsia. Her serum potassium (K) was low at 3.1
mmol/L (3.5–5 mmol/L). Initial tests showed elevated plasma aldosterone, suppressed plasma renin activity and elevated aldosterone-renin ratio (6.61 ng/
dL, <0.1 ng/mL and 66, respectively). Plasma aldosterone after saline suppression test (12.70 ng/dL)
confi rmed the diagnosis of primary aldosteronism
(PA). MRI showed a well-defi ned, oval-shaped solid
nodule in the medial limb of the left adrenal gland
(1.8 x 1.2 cm). Bilateral adrenal vein sampling with
adrenocorticotropic hormone (ACTH) stimulation test
was compatible with BAH (cortisol-corrected aldosterone ratio pre-ACTH stimulation 1.29 and postACTH 1.66), with dominant aldosterone secreting
left adrenal gland (7200 vs 3760 ng/dL). She was
started on spironolactone 200 mg/day and amlodipine 10 mg/day and eventually shifted to eplerenone. Despite the optimal dose of eplerenone and
amlodipine, she still experienced severe headaches,
palpitations and breakthrough elevations of BP that
led to her recurrent admissions. Eplerenone was
shifted back to spironolactone (150-200 mg/day)
with amlodipine dose (10 mg/day) normalizing her
blood pressure and potassium level, yet with persistent headache and muscle weakness. Repeat imaging using CT scan with contrast showed consistent
results. Postoperatively, with all medications discontinued the patient was asymptomatic, normotensive (110/70 mmHg) and normokalemic (4.0 mmol/L).
One month later, her BP started to increase again at
140/80 mmHg and her K decreased to 3.4 mmol/L.
Normalization of said parameters (BP:120/70
mmHg K: 4.1 mmol/L), with stabilization following
lower doses of amlodipine (5mg/day) and spironolactone (25 mg/day). Also, all the symptomatology
of the patient resolved completely.
Conclusion:This present case exemplifi es a unilateral adrenalectomy approach in BAH, which
led to improvement in BP and K levels, despite low
medication doses. Furthermore, symptom relief and
improved quality of life, as desired outcomes, were
achieved.
- Full text:1 JMUST 8.pdf
