Endocrine Abstracts

Adrenal incidentaloma is frequently encountered in endocrinological praxis, however in specific situations the proper investigation is almost impossible. A 60-years old patient was admitted to our intensive care unit with a myocardial infarction in cardiogenic shock requiring ionotropic support and intraaortic balloon counterpulsation. On account of ejection fraction 15–20% an urgent pretransplantation investigation was started. Abdominal ultrasound displayed a hypoechogenic structure 35×30 mm in the left suprarenal region and adrenal CT confirmed a low density mass 25×37 mm. Both aldosterone (886.8 ng/l) and plasmatic renin activity (PRA) (5.9 ng/ml/hod) were highly elevated but our patient was treated with interfering medication (furosemide and spironolactone). Plasma metanephrine levels were within normal limits despite of catecholamine support. The patient had no cushingoid features and ACTH level was normal, but dexametahsone test was falsely positive due to hyperactivation of stress axis and inadequate absorption of dexamethasone. When excluding phaeochomocytoma and malignancy the patient was indicated to urgent heart transplantation. 2 months after the operation, in patient already having normal cardiac function, hypertension and the tendency to hypokalaemia occurred. Elevated aldosterone and supressed PRA were detected. We confirmed the diagnosis of primary hyperaldosteronism by the saline infusion test: basal PRA 0.448 ug/l/hod and aldosterone 182 ng/l; supressed PRA 0.486 ug/l/hod; aldosterone 363 ng/l, the ratio aldosterone/PRA 40 (ng/dl/ng/ml/hod). We did not perform the renal veins cannulation because of the chronic immunosuppressive corticosteroid administration. Left adrenalectomy with histological evidence of adenoma resulted in normalization of blood pressure and potassium levels 6 months after the heart transplantation. An excessive secondary activation of the renin-angiotensin-aldosterone axis in the patient with severe heart failure completely superimposed the original primary hyperaldosteronism pattern.

Disclosure: Supported by the Ministry of Health of the Czech Republic (MZO 00023001).