Case presentation By: Dr - PowerPoint Presentation

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Case presentation

By:Dr Batoul Birjandi

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Case 1

A 45 -year-old woman sought endocrine assessment after being referred by her physician for HTN and hypokalemia. She had a 4-year history of elevated BP at a rate of 160/100 that was discharged as an outpatient after controlling BP. At recent admission in cardiology department she had a BP of 230/110

and

hypokalemia (K=1.2). After correction of hypokalemia and control of BP she was referred to this center.

The patient mentioned that fatigue and weakness had recently bothering her excessively but

s

he denied any recent weight gain, abdominal pains, headaches, palpitations or chest pain.

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PMH: -

DH: Tab losartan 50 mg/bid Tab Amlodipine 5mg/bidFH: HTN in her mother in 50 YOP/E: BP: 120/80 PR: 85/min RR: 14/min T: 36.5 Results of the examination of heart and lungs were unremarkable.The abdominal examination was benign without any

striae,HSM

or abdominal bruits on auscultation. Extremities examination showed no edema or bruises.

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Lab test

variable result Na(meq/l) ……………………………. 143 K(meq/l) …………………………….. 3 FBS(mg/dl)……………………………. 119

BUN(mg/dl)…………………………… 15

Cr(mg/dl) ………………………………. 1.3

Aldosterone(

ng

/dl) ………………… 29.5 PRA(ng/ml/h) ………………………… 0.11 ARR= 290

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PRIMARY ALDOSTERONISM SUBTYPE

subtypeAdrenal CTPrevalence(%)

Aldosterone producing adenoma(APA)

<2cm,

hypodense

nodule

33

Idiopathic

hyperaldosteronism

(IHA)

NL appearing or unilateral or bilateral

nodular change

63

Aldosterone producing carcinoma

Almost always >4cm

and with suspicious imaging phenotype

<1

Primary adrenal hyperplasia

<1

GRA(FH1)

0.5

FH2

3-4

Ectopic aldosterone producing

adema

& carcinoma

Very rare

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Adrenal C

TSize:15.3 *14mm-10 HWell diffined

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C l i n i c a l P r a c t i c e G u i d e l i n

e 2016

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31 studies including 3838 patients with primary

aldosteronism and 9284 patients with essential hypertension. median Follow up of 8·8 yearsSilvia Monticone et al.Lancet Diabetes Endocrinol

2017

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follow-up

patients were invited for follow-up visits at 1 month and then 6–12 months following surgery. This time period was chosen because the full benefit of adrenalectomy – taking into account the gradual decrease in medication – is obtained after 6 months.

BP outcome was classified into three categories recommended by

AHA

for the assessment of BP outcome associated with

renovascular

disease:

hypertension

cure

:systolic

BP (SBP) of

<140mmHg

and

diastolic BP of less than 90mmHg for patients

off

antihypertensive

medication(44%)

improvement

: either

SBP of

<140mmHg

or

diastolic BP

<90mmHg

or

both

, or a

15mmHg

or greater reduction in

diastolic

BP for patients

remaining on the same or less

medication(90-100%)

failure : either as no change in BP or patients not fulfilling the criteria for cure or improvement. Benefit is defined by either cure or improvement

Letavernier

E

et al.

J Hypertens.

 2008 Sep;26(9):1816-23

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Case 2

A 65-year-old man with a history of hypertension was admitted to our hospital  for the evaluation of high blood pressure

.

He had been diagnosed with hypertension at

17

years

ago .

His blood pressure had been well controlled with

2 drugs for 13 years but from 4 years ago he have had uncontrolled BP on multi antihypertensive drugs.

PMH:

DM+( from 25 y ago) /HLP+/ HTN+/ Retinopathy+/ Nephropathy+ /Neuropathy+

FH:+ ( but controlled by fewer drugs)

SH : smoker+ addict+

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DH: -Tab HCTZ 25mg/bid - TAB Carvedilol 3.125mg/bid

-Tab valsartan 160mg/bid

-Tab

Aldactone

25mg/d

-Tab Amlodipine 5mg/d

-Tab terazosin 5mg/bid

-Tab

minoxidil

2.5 mg/bid

Tab metformin 500mg/

tds

NPH Insulin (30…….6)

Reg

Insuli

(6…….6)

Tab ASA 80mg/d

Tab Atorvastatin 20mg/d

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P/E

BP:180/100……..150/90 PR:88/min RR:16 T:36.5 BMI: 34.5Orthostasis changes,negativeAbdomen,no

bruit

Muscle force :5/5

Pitting edema 2+

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CBC:NLFBS:123BUN:18.4Cr:1.1

Uric Acid:4.2TG:62HDL:63Abdominopelvic sono: NL

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Adrenal CTA

15*14mm<10 H

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Adrenal CT

14*17.8mm<10 H

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Lab Test

CBC:NLNa:140K:3.8BUN:22Cr:1.5(GFR:48)Hb A1C: 5.5U/A: Pr +++Aldosterone=19.3 ng

/dl

Renin=2.9micg/ml

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Serum Aldosterone:15.4

ng/dlPRA: 0.44 ng

/ml/h

ARR:34

The patient was treated with the following antihypertensive drugs for one month:

-Tab diltiazem120mg/bid

- Tab hydralazine 50mg/

Tds

-Tab

prazosin

5mg/

Tds

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Case Confirmation:

Four testing procedures: (No gold standard)Oral sodium loading testSaline infusion test (SIT)Fludrocortisone suppression testCaptopril challenge test

*

Choice: cost, compliance, lab routine,

local expertise

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SIT

Lack powerful study designs for establishing the test accuracySensitivity: 83-88%Specificity: 75-100%

2007 J

Hypertens

25:1433-42

Post infusion plasma Aldosterone:

<5

ng

/dl..………unlikely

5-10………intermediate

>10…….very probable

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Our case SIT

Start End PAC (ng/dL)

16 13.5 15.4(2h)

Renin (

µ

IU/ml) 7.6 10.3

Cortisol

(µg/

dL

)

13.1 11.9

Potassium (

mEq

/L) 4.6 4.8

PAC/Cortisol

1.22 1.13

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Ald/Cortisol

Ratio

Measurement of

post SIT

Serum

Ald

/

Cortisol

level

[ if > 3 (

ng

/dl

/

µg/dl), differentiates between APA and IHA (P = 0.001) ]

Journal of Hypertension 2006, 24:737–745

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Elselien

M. Ku¨ pers et al. J clin Endorcinol

Metab

2012

Our patient=3

patients with PA and a

typicalConn’s

adenoma of at least 8 mm on CT scan can

beconsidered

as having unilateral

aldosterone

hypersecretion

if

they also have serum potassium less than 3.5

mmol

/ liter(regardless

of the prescription of potassium

supplements) and/or

eGFR

of at least 100 ml/min/1.73m2. If

this rule

is validated, as much as 30% of PA patients

could avoid

AVS and be directly diagnosed with unilateral PA.

The lowest threshold

5

Subjects

with a score of at least 5

were those

with a typical Conn’s adenoma plus serum

potassium less

than 3.5

mmol

/liter or

eGFR of at least 100 ml/min/1.73 m2 (or both). This criterion had a specificityof100%(95%CI, 91–100) and a sensitivity of53%(95% CI, 38–68) to predict a lateralized

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Unsuccessful or unavailable AVS:

Repeat AVSTreat with MR antagonistConsider surgery based on the other studies:Adrenal CT ScanPosture Stimulation TestMorning Recumbent 18-OHB levels

The

absence of the significant increase (<30%) of PAC at the upright posture supports the diagnosis of APA

Test accuracy: 85%

Fontes

RG, Am J

Hypertens

1991;4:786-9

Young WF,

Endocrinol

Metab

Clin

North Am 1988;17:367-95

The

fall in PAC during 4 h erect posture has PPV of 100% for diagnosis of unilateral lesion

Espiner

EA, J

Clin

Endocrinol

Metab

2003;88:3637-44

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Predictors

of persistent hypertension after adrenalectomy include: older age family

history with

more than one first-degree relative with

hypertension

use

of more than two antihypertensive

drugs preoperatively

duration

of hypertension of more

than 5 yearsconcomitant

essential

hypertension

large gland

size at

operation

increased

serum creatinine levels and

coexistence of other forms of secondary

hypertension.

reduction

in mean BP of 15 mmHg or more

after 10

days of spironolactone therapy, 100

mg/d

,

suggests a

strong likelihood of post-operative cure of

hypertension

Asterios

Karagiannis

et al. Endocrine-Related Cancer (2008) 15 693–700

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Alternatives to

adrenalectomy Mineralocorticoid receptor antagonists – spironolactone and eplerenone - provide a specific treatment for PA in patients who are not candidates for surgery.

Unfortunately, only

a few of these patients show a good

BP response

to spironolactone

monotherapy

. Furthermore, long-term

tolerance of spironolactone at

doses exceeding 50 mg per day is

poor.

There

is no

published evidence

to suggest that high doses of

eplerenone

are

more effective and better tolerated than

spironolactone in

patients with PA. If necessary, lower doses

of aldosterone

receptor antagonists may be associated

with non specific antihypertensive agent.

Amar

et al.

Orphanet

Journal of Rare Diseases

2010,

5

:9

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BP:155/66 PR:67

Tab Aldactone 50mg/bidTab hydralazine 50mg/TDSTab Diltiazem 60 mg/TDsTab Prazosin

5mg/ TDS

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Case 3

A 64 -year-old female with an 2 month history of hypertension presented at our hospital. She was known case of colon adenocarcinoma with total colectomy and chemotherapy (12 se) in 4 year ago.

She has been followed annually with AP CT scan for her cancer.

In the last CT scan in the past 2 month ,the

incidentaloma

has been seen (at the same time with HTN detection) .

PMH: Appendectomy in 62/ hysterectomy 1n 92/ total colectomy in 92

FH: Breast cancer (sister)/ HTN (mother)

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DH: -Tab ditiazem 120 mg/bid

-Tab prazosin1mg/bidP/E:BP: 175/100……..120/80 PR:80 RR:14 T:37Abdominal scar+

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Lab test:

CBC:NL 24 h urine collection: V:850 ccBUN:14 Cr:995mg/dCr:0.9 MN:89.6mcg/dNa:141 NMN:90K:4.1Aldosterone:9.1 ng/dlPRA:0.11ng/ml/h ARR:90

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Our case SIT

Start End PAC (ng/dL) 19.7 6.5 9.1(2h)

Renin (

µ

IU/ml) 1.7 3.9

PRA (

ng

/ml/h) 0.36 2.86

Cortisol

(µg/

dL

)

21.5 3.3

Potassium (

mEq

/L) 3.7 4.1

PAC/Cortisol

0.91 1.9

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Ald/Cortisol

Ratio

Measurement of

post SIT

Serum

Ald

/

Cortisol

level

[ if > 3 (

ng

/dl

/

µg/dl), differentiates between APA and IHA (P = 0.001) ]

Journal of Hypertension 2006, 24:737–745

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CPS:3

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BP: 120/80 PR:80 Tab ditiazem 120 mg/bid

Tab prazosin1mg/bid

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Panagiota Economopoulou et al.Case Reports in Medicine. Volume 2013(2013)

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