The problem of timely diagnosis of primary hyperaldosteronism. Clinical case

Abstract

A clinical case is presented of delayed diagnosis of primary hyperaldosteronism (PHA) due to aldosterone-producing adenoma. Suspicion of PHA arises in case of persistent combination of hypertension with hypokalemia of various severity, a specific neuromuscular syndrome, as well as a high risk of cardiomyopathy, heart failure, and deterioration of kidney function, which are not typical for banal hypertension. Unsatisfactory blood pressure control with a standard combination of pharmacotherapy, an unexpected positive effect of mineralocorticoid receptor antagonists, high blood pressure in young people, as well as a family history of early high blood pressure or stroke at a young age, paroxysmal course of hypertension itself increases the risk of PHA. For a long time, a disease in our patient was considered a banal hypertension, although the diagnostic hypothesis of PHA should appear immediately after severe neuromuscular syndrome, rapid progression of cardiomyopathy and clinically significant heart failure began to dominate in the clinical picture. A 44-year-old female patient came to the attention of rheumatologists with suspicion of inflammatory myopathy due to frequent episodes of muscle weakness whose origin remained unclear. Key complaints of pronounced paroxysmal generalized muscle weakness, especially in the limbs, numbness and paresthesias in the extremities, calf muscle cramps against the background of hypertension were regarded as a neuromuscular syndrome specific to PHA. The PHA hypothesis was supported by the presence of cardiomyopathy, heart failure, clinically significant hypokalemia, and elevated aldosterone level. Computed tomography of the retroperitoneal space confirmed the presence of adrenal adenoma. Unfortunately, with a delay, after 13 years of hypertension, the diagnosis of PHA against the background of aldosterone-producing adenoma was confirmed. Consultation with a surgeon endocrinologist was suggested, as well as administration of eplerenone 50 mg daily in combination with lercanidipine 20 mg daily. Already after 6 weeks of pharmacotherapy, a positive therapeutic effect was obtained regarding the control of hypertension, heart failure, and the severity of neuromuscular syndrome. The differential diagnosis of secondary endocrine hypertension can be successful only with the possession of skills for early clinical detection of endocrine pathology, even in subclinical disease presentation. The diagnosis of PHA makes it possible to offer a patient radical surgical treatment, as well as to choose optimal approaches to pharmacotherapy.

Keywords

• primary hyperaldosteronism
• aldosterone-producing adenoma
• hypokalemia
• secondary hypertension
• hyperaldosteronism