Endocrine Abstracts

Africo Caribbean gentleman was referred to our endocrine department for management of secondary hypertension. He initially presented to his doctor with headache and he was found to be hypertensive with systolic BP of 200 mmHg and hypokalaemia. A renal MRI showed a right adrenal mass, 2.9×2.4 cm, and echocardiogram showed moderate left ventricular hypertrophy and diastolic dysfunction. He had normal 24 h excretion of metanephrines and free cortisol. An aldosterone renin ratio, after stopping interfering drugs, was 2320, consistent with Conn’s syndrome. He also had a saline suppression test, which showed baseline aldosterone to renin ratio of 5700 and post saline infusion, the aldosterone remained elevated at 250 pmol/l. Subsequently he had adrenal venous sampling (AVS) that showed right adrenal aldosterone-to-cortisol (AC) ratio at 3.4, a left adrenal ratio of 8.3 and an IVC ratio of 3.3. The lateralisation index was left dominant at 2.44 (8.3/3.4), contralateral suppression index was 1.03 (3.4/3.3). This was interpreted as being suggestive of bilateral disease. He had repeat MRI Adrenal and comparison was made with previous MRI. The 2.5 cm right adrenal lesion was unchanged in size and appearances and the left adrenal gland appeared normal. He had an FDG-PET scan that showed right adrenal lesion, demonstrated low level FDG uptake. The level of metabolic activity in the left adrenal is within the normal limits. Currently he is on Spironolactone 75 mg OD, Valsartan 160 mg and Amlodipine 10 mg. He feels ‘washed out and weak’, and would like to consider surgical options for the treatment of his Primary hyperaldosteronism. The presentation will focus on the following questions:

(1) Does this gentleman require adrenal surgery, and if so, what would be the recommended procedure?

(2) Are additional investigations required before surgery can be recommended?

(3) Are alternative medical treatments required for the hypertension?