Endocrine Abstracts

Primary Aldosteronism (PA) can be due to a variety of underlying pathologies, predominantly aldosterone-producing adenomas and adrenal hyperplasia. PA is one of the leading causes of secondary hypertension in young patients. We describe the case of a young male presenting with a stroke in 2012, six years later he had a second ischaemic event and was noted to have treatment resistant hypertension. This constellation of symptoms prompted an investigation revealing hypertension, hypokalemia, and elevated aldosterone:renin ratios, culminating in a diagnosis of PA. However multiple imaging modalities including CT, MRI, PET-CT across a 6 year period were unable to identify any adrenal adenoma/ hyperplasia. Nine years after his initial stroke this patient was found to have mildly enlarged bilateral adrenal glands, with micronodular appearance, this was reported as a 12mm left adrenal lesion with 77% absolute washout on CT imaging. Subsequent adrenal vein sampling (AVS) revealed lateralisation to the right adrenal gland, adding complexity to the diagnostic puzzle. Here we have a case where the aldosterone secreting lesion was initially unable to be localised, then contradictory data between imaging and AVS. In this case PET-CT did not demonstrate an adrenal lesion. Recent Nature research has demonstrated non-inferiority between Metomidate PET-CT and AVS; however the access to such imaging techniques is a challenge. This case poses questions for Endocrinologists due to standard diagnostic techniques giving seemingly contradictory localisation of the lesion. Moreover, the chronology of the events in this case creates another unanswered question: whether this gentleman had two subsequent pathological processes (one being micro-tumours followed by an unrelated adrenal lesion) or whether we were simply unable to identify where the tumour was initially. These uncertainties underscore the complexities of diagnosing and managing PA, urging further exploration into novel diagnostic approaches and refining existing methodologies to improve patient outcomes.