Endocrine Abstracts

Seventy six-year-old man was referred to our hospital for examination of hypertension and hypokalemia. His blood pressure was uncontrolled although he was taking amlodipine besilate, spironolacton and candesartan. In addition, he suffered from atrial fibrillation and chronic heart failure. His serum potassium was low (2.8 mmol/l) and bilateral adrenal glands were found swelling. Hence, we investigated him thoroughly on the suspicion for primary aldosteronism.

Unexpectedly, plasma renin activity (PRA, 0.1 ng/ml per h) and aldosterone concentration (PAC, 10.0 pg/ml) were low. On the other hand, diurnal variation of plasma ACTH and cortisol were lost with suppression of ACTH. At overnight fast, plasma levels of ACTH and cortisol were 4.0 pg/ml (7.2–63.3) and 15.5 μg/dl (4.0–18.2) respectively, and administration of 1 mg nor 8 mg dexamethasone neither suppressed serum cortisol levels. Abdominal CT and MRI revealed bilateral adrenal tumor (right 12×10 mm, left 12×5 mm in diameter). ¹³¹I-adosterol scintigraphy showed bilateral high uptake. On the basis of these findings, we considered possibility of subclinical Cushing’s syndrome; however, the causes of hypokalemia and hypertension still remained to be explained.

For differential diagnosis of low-renin, low-aldosterone hypertension, we measured serum DOC and urine THE/THF ratio both of which were within normal range. Liddle syndrome was less likely because of the age of onset.

After admission, his blood pressure returned to be normal without any change in medication. Then, he noticed that he had casually drunk a lot of green juice, which was ceased after admission. Green juice is one of the popular vegetable juices in Japan, and contains licorice. Hence, we concluded that he has pseudo-aldosteronism complicated with subclinical Cushing’s syndrome. It could be considered that inhibition of 11βHSD type 2 by licorice in the patient with latent excess of cortisol may develop severe hypokalemia and hypertension through mineralocorticoid receptor.

Declaration of interest: The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project.

Funding: This research did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.