SFEIES24 Poster Presentations Adrenal & Cardiovascular (40 abstracts)
Primary aldosteronism in a patient with cushing’s disease in remission
Maria Tomkins 1,2 , Darran Mc Donald 1,2 , Jack Lee 2 , Julie Martin-Grace 1,2 , Claire Carthy 2 , John Finnegan 3 , Douglas Mulholland 3 , Neal Dugal 4 , Michael W. O’Reilly 1,2 & Mark Sherlock 1,2
1Academic Division of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland; 2Department of Endocrinology, Beaumont Hospital, Dublin, Ireland; 3Department of Interventional Radiology, Beaumont Hospital, Dublin, Ireland; 4Department of Urology, Beaumont Hospital, Dublin, Ireland
A 47-year-old man attending with a history of Cushing’s disease in remission following transsphenoidal surgery in 2013 continued to experience resistant hypertension which warranted further investigation. Postoperatively he was prescribed hydrocortisone 10 mg twice daily and desmotab 0.2 mg nocte for ACTH deficiency and diabetes insipidus. Over the course of six years antihypertensive therapy escalated until he required five agents – ramipril 10 mg, amlodipine 10 mg, bisoprolol 10 mg, spironolactone 100 mg, doxazosin 8 mg. He had ambulatory blood pressure monitor daytime average of 142/85mmHg and nighttime average of 150/88mmHg with episodes of spontaneous hypokalaemia and symptoms suggestive of obstructive sleep apnoea. Initial investigations ruled out Cushing’s disease recurrence, cortisol 11 nmol/l post-1 mg overnight dexamethasone suppression test. Biochemical work-up revealed elevated aldosterone 877 pmol/l, and a fully suppressed renin <5mIU/l, normal potassium 3.9 mmol/l and normal plasma metanephrines, taken whilst off beta-blockers. Aldosterone-renin ratio was 175.4 suggestive of primary aldosteronism. Difficult-to-control hypertension significantly compromised the interpretability of biochemical workup. Equally, a saline suppression test was not suitable. Cross-sectional imaging revealed a 1.2cm left adrenal nodule (35 Hounsfield units). On the first attempt of adrenal vein sampling, there was a failure to cannulate the right adrenal vein. Repeat testing was successful and lateralized to the left adrenal gland, with a lateralization index of 39.5 and a contralateral suppression index of 0.18. He underwent robotic-assisted left adrenalectomy in March 2024, histology confirmed a 9mm adrenocortical nodule. He was discharged home on amlodipine 10 mg and bisoprolol 10 mg with excellent blood pressure control. Key learning points from this case centre around the diagnostic workup of primary aldosteronism including the interpretability of biochemistry during antihypertensive agent use, and the interpretation of adrenal vein sampling results. It also highlights the importance of considering alternative endocrine diagnoses in patients attending the outpatient clinic.
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Endocrine Abstracts
ISSN 1470-3947 (print) | ISSN 1479-6848 (online)
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