NYU Medical Grand Rounds NYU Medical Grand Rounds Clinical VignetteClinical Vignette

Michael Chu MD, PGY-2Michael Chu MD, PGY-2

5/20/095/20/09

Chief ComplaintChief Complaint

71 year old male with difficult to control 71 year old male with difficult to control hypertension for approximately 15 yearshypertension for approximately 15 years

History of Present IllnessHistory of Present Illness

The patient was noted by his primary care The patient was noted by his primary care physician to have difficult to control physician to have difficult to control hypertension despite being treated with hypertension despite being treated with five antihypertensive medicationsfive antihypertensive medications

The patient was largely asymptomaticThe patient was largely asymptomatic

Noted to require potassium Noted to require potassium supplementation to maintain normal supplementation to maintain normal potassium levels potassium levels

Additional HistoryAdditional History

Past Medical History:Past Medical History:– HypertensionHypertension– Type II Diabetes MellitusType II Diabetes Mellitus– GlaucomaGlaucoma– DiverticulosisDiverticulosis

Past Surgical History:Past Surgical History:– nonenone

Additional HistoryAdditional History

Social History:Social History:– Previous tobacco use, quit 10-15 years priorPrevious tobacco use, quit 10-15 years prior– 1-2 drinks of alcohol 3-4 times per week1-2 drinks of alcohol 3-4 times per week– Works as a plumber and owns businessWorks as a plumber and owns business

Family History:Family History:– No history of heart disease or diabetes in the No history of heart disease or diabetes in the

familyfamily– Sister died of a brain tumor in her 70sSister died of a brain tumor in her 70s

MedicationsMedicationsAllergies: Allergies: – Lisinopril (lip swelling)Lisinopril (lip swelling)

Medications:Medications:– Aspirin 325mg PO dailyAspirin 325mg PO daily– Atenolol 50mg PO dailyAtenolol 50mg PO daily– Chlorthalidone 25mg PO dailyChlorthalidone 25mg PO daily– Hydralazine 50mg PO BIDHydralazine 50mg PO BID– Losartan 50mg PO BIDLosartan 50mg PO BID– Nifedipine 90mg PO dailyNifedipine 90mg PO daily– Potassium Chloride 40 meq PO BIDPotassium Chloride 40 meq PO BID– Simvistatin 20mg PO dailySimvistatin 20mg PO daily– Metformin 1000mg PO BIDMetformin 1000mg PO BID– Timolol eye dropsTimolol eye drops

Physical ExamPhysical Exam

General: Well appearing male in no acute General: Well appearing male in no acute distressdistress

Vital Signs: T:98.7 BP:139/88 HR:62 Vital Signs: T:98.7 BP:139/88 HR:62 RR:16 RR:16

Trace pedal edema was noted in his lower Trace pedal edema was noted in his lower extremities bilaterallyextremities bilaterally

Otherwise the remainder of his physical Otherwise the remainder of his physical exam was normalexam was normal

Laboratory FindingsLaboratory Findings

CBC: Hemoglobin 12.7 g/dL Hematocrit 37.1%CBC: Hemoglobin 12.7 g/dL Hematocrit 37.1%– Remainder of the CBC was within normal limitsRemainder of the CBC was within normal limits

Basic Metabolic panel: Potassium 3.4 mEq/L, Basic Metabolic panel: Potassium 3.4 mEq/L, previously had been as low as 3.0 mEq/Lpreviously had been as low as 3.0 mEq/L– Remainder of the BMP was within normal limitsRemainder of the BMP was within normal limits

Hepatic panel: Hepatic panel: within normal limitswithin normal limits

Aldosterone level 10.9 ng/dL (Ref. range 1.0-16)Aldosterone level 10.9 ng/dL (Ref. range 1.0-16)Plasma Renin Activity 0.2 ng/mL/hr (Ref. range 0.3-Plasma Renin Activity 0.2 ng/mL/hr (Ref. range 0.3-3)3)Aldosterone/Renin ratio elevated > 50Aldosterone/Renin ratio elevated > 50– Ratio > 20 suggestive of primary hyperaldosteronismRatio > 20 suggestive of primary hyperaldosteronism

ImagingImaging

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

Differential DiagnosisDifferential Diagnosis

Hyperfunctioning adenoma, such as a Hyperfunctioning adenoma, such as a pheochromocytoma or aldosterone pheochromocytoma or aldosterone secreting tumorsecreting tumor

Non-functioning adenomaNon-functioning adenoma

Bilateral adrenal hyperplasiaBilateral adrenal hyperplasia

Adrenal cancerAdrenal cancer

Metastatic cancerMetastatic cancer

MyelolipomaMyelolipoma

Clinic CourseClinic Course

The patient was referred to the endocrinology clinic for The patient was referred to the endocrinology clinic for further management and repeat lab testing was further management and repeat lab testing was performedperformed

Aldosterone level 28.3 ng/dL Aldosterone level 28.3 ng/dL

Plasma Renin Activity level 0.48 ng/mL/hr Plasma Renin Activity level 0.48 ng/mL/hr

Aldosterone/Renin ratio elevated > 50Aldosterone/Renin ratio elevated > 50

24 hour urine catecholamine and metanephrines was 24 hour urine catecholamine and metanephrines was within normal limitswithin normal limits

Salt loading testing was performed and serum Salt loading testing was performed and serum aldosterone level was noted to be non-suppressed aldosterone level was noted to be non-suppressed

Clinic CourseClinic Course

It was recommended for the patient to undergo It was recommended for the patient to undergo adrenal vein sampling to differentiate between an adrenal vein sampling to differentiate between an aldosterone secreting adenoma and bilateral aldosterone secreting adenoma and bilateral adrenal hyperplasia, however the patient opted for adrenal hyperplasia, however the patient opted for medical managementmedical management

The patient was started on spironolactone therapyThe patient was started on spironolactone therapy

Since beginning spironolactone, the was able to Since beginning spironolactone, the was able to come off of Chlorthalidone, Hydralazine and come off of Chlorthalidone, Hydralazine and potassium supplementationpotassium supplementation

Final DiagnosisFinal Diagnosis

Primary HyperaldosteronismPrimary Hyperaldosteronism