Case Study:
Patient: Sarah, a 42-year-old woman with a 5-year history of hypertension, diagnosed at age 37.
Presenting Symptoms: Sarah initially presented with persistent headaches, excessive thirst, and frequent urination. She also reported occasional muscle weakness and cramps.
Medical History: Sarah had no significant medical history. She was a non-smoker and drank alcohol occasionally. Her family history included hypertension in her father.
Initial Investigations: Blood pressure measurement revealed 160/100 mmHg despite taking two antihypertensive medications. Laboratory tests showed elevated blood sodium (148 mmol/L), low blood potassium (3.1 mmol/L), and normal blood glucose and creatinine levels.
Diagnostic Workup: Suspecting secondary hypertension, the physician ordered further tests. Plasma renin activity (PRA) was found to be suppressed, and the aldosterone-to-renin ratio (ARR) was significantly elevated, hinting at primary aldosteronism. An abdominal CT scan revealed a 1 cm adenoma on the left adrenal gland.
Diagnosis: Based on the clinical picture, laboratory findings, and imaging result, Sarah was diagnosed with primary aldosteronism due to an aldosterone-producing adenoma (APA).
Treatment Plan: Due to the small size of the adenoma and Sarah’s age, the recommended treatment was laparoscopic adrenalectomy. She was also prescribed a mineralocorticoid receptor antagonist (MRA), spironolactone, to control blood pressure and potassium levels pre-operatively.
Outcome: The laparoscopic adrenalectomy was successful, and Sarah’s blood pressure and potassium levels normalized within weeks. She continued taking spironolactone for a while as a precaution and gradually tapered down her other antihypertensive medications.
Sarah remained hypertensive-free for 3 years following surgery. Her electrolytes remained within normal range, and she reported significant improvement in her symptoms, including reduced headaches, fatigue, and muscle weakness.
Discussion: This case illustrates the typical presentation of primary aldosteronism with hypertension, hypokalemia, and metabolic alkalosis. Early diagnosis and prompt treatment, as seen in Sarah, can lead to successful blood pressure control and improved quality of life. However, long-term follow-up is crucial as recurrence can occur in some cases.
Additional Points:
- This case highlights the importance of considering secondary causes of hypertension, especially in young patients or those with resistant hypertension.
- The case emphasizes the utility of specific investigations like elevated ARR and adrenal imaging in pinpointing the diagnosis of primary aldosteronism.
- Minimally invasive surgical techniques like laparoscopic adrenalectomy offer a less invasive and effective treatment option for suitable patients.
- Long-term management requires monitoring blood pressure, electrolytes, and adrenal function for potential recurrent aldosterone excess.
By delving into Sarah’s case, we gain valuable insights into the presentation, diagnosis, and management of primary aldosteronism, showcasing the importance of vigilance and comprehensive care for this potentially curable disorder.