Endocrine Abstracts

A 63-year-old gentleman was admitted with right iliac fossa pain, nausea and constipation. Incidentally his potassium was found to be 2.3 mmol/l and he had ureteric stent insertion for right VUJ calculus after the potassium was corrected. Endocrine consultant who reviewed him in the acute medical unit advised an aldosterone to renin ratio (ARR)which was raised with aldosterone 920 and suppressed renin <0.2 but he was still taking Ramipril 5 mg, Amlodipine 10 mg and Doxazosin 4 mg OD despite the correct instructions. A saline suppression test was performed to avoid any further delay in the diagnosis after he came off Amlodipine and Ramipril for 2 weeks. His ARR was raised with Aldosterone level of 730 pmol/l and plasma renin activity of <0.2. Post 2 L of saline infusion, his aldosterone level suppressed to 230 pmol/l with a persistently low PRA <0.2 making the diagnosis of primary hyperaldosteronism unsure (level >240 is highly probable for PA whilst anything <120 is highly unlikely). A dedicated CT adrenal glands showed bilateral adrenal nodularity with a slightly more hyperplastic left gland. He was then referred to Adrenal MDT and AVS results are shown below. He was commenced on Eplerenone 100 mg OD with plan to discontinue the latter 2 weeks prior.The above was suggestive of right sided adrenal source of aldosterone excess and thus he had a laparoscopic right adrenalectomy. Post operatively, his BP normalised and he remained normokalemic with a normal ARR and adequate response to synacthen. His adrenal gland histology was reported as nodular and diffuse hyperplasia. During his last endocrine clinic visit, his BP 140/83 whilst on Amlodipine 5 mg OD, Furosemide 20 mg OD, Doxazosin 4 mg OD and he was also commenced on Carbimazole for toxic multinodular goitre picked up on ultrasound when his TFTs showed a primary hyperthyroidism. This case is interesting as the low potassium wasn’t picked up for several years until seen by an endocrinologist during the medical take. This case highlights the importance of educating primary care who deal with management of hypertension and other specialists such as urologists who deal with adrenal incidentaloma.