<Brief
History> The
37-year-old gentleman was hospitalized because of hypertension
with hypokalemia for 9 years. He firstly experienced a sudden
onset of severe throbbing headache in 1991 when he was
teaching. Hypertension with blood pressure up to 180/100 mmHg
was found. Therefore, he visited hospital A. After a series of
examinations, hypokalemia (less than 3 mEq/L) and a small left
adrenal tumor were detected. He took medication since then.
However, his blood pressure was not well controlled. He still
had intermittent headache and he remained hypokalemic. He did
not have symptoms of hypokalemia, such as malaise, fatigue or
constipation except occasional leg weakness after rigorous
exercise.
He visited hospital
B on February 3, 1993. A CT scan of the abdomen demonstrated a
nodule in the left adrenal gland. An 13I
I-NP59
scan showed symmetrically increased uptake in both adrenals.
Then, adrenal venous sampling was performed. The aldosteorone
and cortisol levels were 283/65.8 in the right adrenal vein,
198/21.3 in the left adrenal vein, and 357/42.8 in the
inferior vena cava, respectively (aldosterone in ng/dl,
cortisol in μg/dl). No
definite diagnosis was made. Thereafter, he took various
drugs, including labetalol, prazocin, hydralazine, and
spironolactone, from different hospitals.
General weakness,
headache, and epistaxis developed on January 9, 2000. On the
next day, he suffered from headache, palpitation, and flushing
sensation. So, he was admitted to hospital C. Again,
hypertension was noted (SBP over 200 mmHg). He received
several examinations, including 24-hr urine potassium
excretion, a postural test, and a CT scan of the abdomen,
which demonstrated a 1.3 cm tumor in the left adrenal gland
(Figure 1
). Then, he was hospitalized to
our hospital on March 2 for adrenal venous sampling after
spironolactone was discontinued for one week. Physical
findings were unremarkable except hypertension.
<Lab
Data> 1. CBC+DC (2/23):
RBC |
Hb |
Hct |
MCV |
Plt |
WBC |
4.55M |
13.1 |
37.4 |
82.2 |
187K |
4.97K |
2. BCS:
|
Na |
K |
Cl |
Ca |
Mg |
2/23 |
140 |
3.1 |
106 |
2.4 |
-- |
2/25 |
142 |
2.7 |
103 |
2.19 |
0.93 |
A/G |
Bil (T/D) |
GOT/GPT |
ALP |
g-GT
|
BUN/Cre |
4.2/3.5 |
1.0/0.3 |
14/14 |
127 |
22 |
15.4/1.1 |
3.ABG:
pH |
PaCO2 |
PaO2 |
HCO3 |
7.45 |
40.8 |
94.4 |
27.7 |
4. Urine:
VMA |
Dopamine |
Epinephrine |
NE |
pH |
5.5 (1--7) |
301 (50--45) |
23.8 (<22.4) |
90 (12--85) |
6.5 |
Amount |
Cl |
K |
Na |
Osm |
3,000 cc |
22 |
13.5 |
27 |
245
| 5. Postural test:
|
8 AM |
12 noon |
Plasma renin activity (ng/ml/hr) |
0.26 |
0.21 |
Aldosterone (ng/dl) |
92.40 |
47.20 |
Cortisol (μg/dl) |
16.34 |
6.99 |
6. Adrenal venous sampling:
|
PRA (ng/ml/hr) |
Aldo (ng/dl) |
Cortisol (μg/dl) |
Ratio |
Peripheral |
0.09 |
84.2 |
15.84 |
5.3 |
IVC above |
0.07 |
134.2 |
20.78 |
6.5 |
IVC below |
0.12 |
101.3 |
18.39 |
5.5 |
Left adrenal |
0.08 |
442.1 |
57.1 |
7.7 |
Right adrenal |
0.13 |
90.9 |
14.26 |
6.4 |
<Course
and
Treatment> After
admission, 24-hr urine was collected for measuring the
excretion amount of potassium, VMA, and catecholamines.
Bilateral adrenal sampling was performed smoothly on February
25, 2000. Ophthalmologists were consulted and his eye ground
was found to be normal. Left adrenalectomy was performed on
April 1. Macroscopically, a 1.3-cm yellow soft tumor was
found. Microscopically, it was an adrenocortical adenoma(Figure2
). His BP was 130/90 mmHg before discharge. Enalapril 5 mg qd was
prescribed. He returned to the urology clinic 6 days later.
His blood pressure was 150/110 mmHg. The serum potassium level
was 4.4 mEq/L.
病案分析 由高血壓與低鉀血症可懷疑此病例有續發性高血壓,進一步的檢查雖發現左側腎上腺有一腫瘤,但131I
-NP59 scan與第一次adrenal
venous sampling並未證明該腫瘤具有分泌功能。此次住院,從plasma
renin activity與aldosterone的變化可推測病人罹患primary aldosteronism,再由postural
test配合電腦斷層攝影結果更加支持病人左側腎上腺有aldosterone-producing tumor,故開刀切除之。
|