Endocrine Abstracts

Introduction: Antidepressants especially SSRI are widely used in all ages. Increase in serotonin level is not supposed to give side effects in other hormonal systems. Here we present a case with serotonergic like symptoms, elevated aldosterone levels and hypertension due to sertraline treatment.

Clinical Case: A 37-year-old woman with previous PCÓs was admitted due to hypertension and high aldosterone. She had undergone two pregnancies after letrozole treatment, with one living child and one miscarriage, and still wishing for pregnancy. Due to depression, she was medicated with sertraline 150 mg daily, starting at 50 mg. Aldosterone was 862 pmol/l (28-540 pmol/l), aldosterone/renin-ratio 66 (<23), saline infusion showed insufficient suppression of aldosterone while renal arteries, dexamethasone-suppression test, and 17-OH-progesterone were normal. CT adrenal scan and adrenal vein catheterization were not clearly conclusive but leaned towards dominance for right side. A unilateral adrenalectomy was performed. Histopathology was not possible due to destroyed tissue. Blood pressure and aldosterone levels normalized initially. After 6-8 months, the patient complained of tiredness, weakness, headache, sweating and diarrhea. Aldosterone rose to 1570 pmol/l and blood pressure to 145/95. Sertraline and desmetylsertraline were very high, 656 nmol/l (median 112; 10-90:e percentile 39-244) and 1450 nmol/l (median 201; 10-90:e percentile 32-407), respectively, despite normal dosage. CYP2C9 and CYP2D6, of importance for metabolizing sertraline, were found normal. Grape fruit was not consumed. Dexamethasone for two weeks did not decrease aldosterone levels. Serotonergt syndrome was suspected, and sertraline was gradually decreased. Blood pressure and aldosterone levels slowly normalized. IVF treatment succeeded.

Clinical message: The high plasma level of sertraline in this patient is still unexplained. Sertraline in recommended dose can significantly increase the level of aldosterone leading to hypertension. The stimulation of aldosterone is probably mediated by serotonin with a direct effect on zona glomerulosa.