Systemic Hormonal Unloading in Unilateral Adrenalectomy in a Patient with Bilateral Adrenal Hyperplasia: A Case Report
Ma. Felisse Carmen Gomez, Florence Rochelle Gan, Erick Mendoza, Leilani B. Mercado Asis
Apr 2019 DOI 10.35460/2546-1621.2018-0055 Access
Background: Unilateral adrenalectomy has not been recommended in the guidelines as a treatment for primary hyperaldosteronism secondary to bilateral adrenal hyperplasia (BAH). Interestingly, recent studies have shown that increased circulation of aldosterone increased oxidative stress, cardiovascular (CV) complications such as atrial fibrillation, myocardial infarction and heart failure; and that unilateral adrenalectomy led to improved CV function. Therefore, recognizing the role of unilateral adrenalectomy in BAH, specifically for improved quality of life is important.
Clinical case: A 47‐year-old hypertensive (highest blood pressure [BP] 150/90 mmHg) woman had a severe headache, muscle weakness, polyuria, and polydipsia. Her serum potassium (K) was low at 3.1 mmol/L (3.5–5 mmol/L). Initial tests showed elevated plasma aldosterone, suppressed plasma renin activity and elevated aldosterone-renin ratio (6.61 ng/dL, <0.1 ng/mL and 66, respectively). Plasma aldosterone after saline suppression test (12.70 ng/dL) confirmed the diagnosis of primary aldosteronism (PA). MRI showed a well-defined, oval-shaped solid nodule in the medial limb of the left adrenal gland (1.8 x 1.2 cm). Bilateral adrenal vein sampling with adrenocorticotropic hormone (ACTH) stimulation test was compatible with BAH (cortisol-corrected aldosterone ratio pre-ACTH stimulation 1.29 and post-ACTH 1.66), with dominant aldosterone secreting left adrenal gland (7200 vs 3760 ng/dL). She was started on spironolactone 200 mg/day and amlodipine 10 mg/day and eventually shifted to eplerenone. Despite the optimal dose of eplerenone and amlodipine, she still experienced severe headaches, palpitations and breakthrough elevations of BP that led to her recurrent admissions. Eplerenone was shifted back to spironolactone (150-200 mg/day) with amlodipine dose (10 mg/day) normalizing her blood pressure and potassium level, yet with persistent headache and muscle weakness. Repeat imaging using CT scan with contrast showed consistent results. Postoperatively, with all medications discontinued the patient was asymptomatic, normotensive (110/70 mmHg) and normokalemic (4.0 mmol/L). One month later, her BP started to increase again at 140/80 mmHg and her K decreased to 3.4 mmol/L. Normalization of said parameters (BP:120/70 mmHg K: 4.1 mmol/L), with stabilization following lower doses of amlodipine (5mg/day) and spironolactone (25 mg/day). Also, all the symptomatology of the patient resolved completely.
Conclusion: This present case exemplifies a unilateral adrenalectomy approach in BAH, which led to improvement in BP and K levels, despite low medication doses. Furthermore, symptom relief and improved quality of life, as desired outcomes, were achieved.
Hormonal unloading, primary aldosteronism, hypertension, bilateral adrenal hyperplasia, hyperaldosteronism, case report
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