Resistant hypertension with adrenal nodule: are we removing the right gland?

[摘要] Resistant hypertension is often difficult to treat and may be associated with underlying primary aldosteronism (PA).We describe the case of an elderly gentleman who presented with severe and resistant hypertension and was found to have aleft adrenal incidentaloma during evaluation but had aldosterone excess secondary to unilateral adrenal hyperplasia (UAH)of the contralateral gland, which needed surgical intervention. A 65-year-old gentleman was evaluated for uncontrolledhigh blood pressure (BP) in spite of taking four antihypertensive medications. The high BP was confirmed on a 24-hambulatory reading, and further biochemical evaluation showed an elevated serum aldosterone renin ratio (ARR)(1577 pmol/l per ng per ml per h). Radiological evaluation showed an adrenal nodule (15 mm) in the left adrenal gland butan adrenal vein sampling demonstrated a lateralization towards the opposite site favouring the right adrenal to be thesource of excess aldosterone. A laparoscopic right adrenalectomy was performed and the histology of the glandconfirmed nodular hyperplasia. Following surgery, the patient’s BP improved remarkably although he remained onantihypertensives and under regular endocrine follow-up. PA remains the most common form of secondary and difficultto-treat hypertension. Investigations may reveal incidental adrenal lesions, which may not be the actual source of excessaldosterone, but UAH may be a contributor and may coexist and amenable to surgical treatment. An adrenal vein samplingshould be undertaken for correct lateralization of the source, otherwise a correctable diagnosis may be missed and theincorrect adrenal gland may be removed.

[学科分类] 血液学

[关键词] Adult;Male;White;United Kingdom;Adrenal;Adrenal;Aldosterone;Renin;Cortisol;Incidentaloma;Unilateral adrenal hyperplasia;Nodular hyperplasia;Hyperaldosteronism;Conn's syndrome;Hypertension;Pallor;Adrenal venous sampling;Aldosterone to renin ratio;Blood pressure;ACTH stimulation;MRI;Histopathology;Laparoscopic adrenalectomy;Adrenalectomy;Spironolactone;Diltiazem;Amlodipine;Irbesartan;Angiotensin receptor antagonists;Cardiology;Insight into disease pathogenesis or mechanism of therapy;October;2015