Rare dual diagnosis explains man’s chronic high blood pressure: Report
Asymptomatic Cushing's plus PHA found to be cause in challenging case
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Asymptomatic Cushing’s syndrome alongside primary hyperaldosteronism, or PHA — a disorder marked by excessive secretion of the hormone aldosterone — was found to be the cause of persistent, hard-to-treat high blood pressure in a 57-year-old man, according to a new case study.
The research team, from Iran, noted the “diagnostic challenges” posed by this case, and stressed — as one of the “key clinical messages” of their report — that “co-occurrence of pathologies [disease causes and characteristics] may occur” in patients with chronic high blood pressure.
According to the team, “patients may have more than one cause for secondary [high blood pressure], which may reduce their response to treatment.”
In this case, the man’s PHA, characterized by excessive aldosterone, which leads to high blood pressure, was caused by a disease of the left adrenal gland. His Cushing’s syndrome was caused by a right adrenal tumor that produced excess cortisol, but not enough to cause fully symptomatic disease.
The study, “Diagnostic Challenges of Adrenal Venous Sampling for Primary Hyperaldosteronism in a Patient With Subclinical Cushing’s Syndrome: A Case Report,” was published in Clinical Case Reports.
Cushing’s syndrome, also referred to as hypercortisolism, is a condition marked by persistently high levels of the stress hormone cortisol in the bloodstream.
It can be caused by tumors in the brain’s pituitary gland, when it’s then called Cushing’s disease, or a tumor in the adrenal glands, which sit atop the kidneys, that secretes excess cortisol. Among the symptoms of Cushing’s is hypertension, or high blood pressure.
Man with 20-year history of high blood pressure saw new symptoms
This report describes the case of a man in his 50s with a 20-year history of hypertension, despite ongoing targeted medical treatment.
In the prior year, his blood pressure had been poorly controlled, and for the past nine months, he had complained of abdominal pain. Three years earlier, he had experienced an intracranial hemorrhage, or a brain bleed. Still, there was no tenderness found in an abdominal examination, and he didn’t have signs of overt Cushing’s syndrome, the researchers noted.
Blood tests revealed low levels of renin, an enzyme produced by the kidneys, and elevated levels of aldosterone, a hormone that helps regulate blood pressure. These results suggested PHA, which is marked by excessive aldosterone secretion from the adrenal glands, causing the body to retain sodium (salt) and lose potassium, leading to high blood pressure. A CT scan then revealed a mass in the right adrenal gland.
To confirm these findings, the man underwent adrenal venous sampling. This minimally invasive procedure involves collecting blood directly from the adrenal veins to see if one or both glands are overproducing hormones.
The results suggested that the left adrenal gland, rather than the right, was the most likely source of excess aldosterone and PHA.
Additional testing to characterize the right adrenal mass revealed mild autonomous cortisol secretion (MACS), a condition in which an adrenal tumor produces excess cortisol, but not enough to cause full-blown Cushing’s syndrome.
After treatment, man’s blood pressure dropped
The man was diagnosed with PHA, likely due to adrenal hyperplasia, a disease of the adrenal glands, and MACS. He opted for medical therapy with hypertension drugs, along with long-term follow-up rather than surgery.
One month after treatment began, his blood pressure dropped to slightly above the normal range.
According to the research team, this case highlights the need to consider other causes for high blood pressure when PHA is determined.
“In the setting of hyperaldosteronism, it’s essential to biochemically confirm that an incidental adrenal mass is responsible for excess aldosterone secretion because co-occurrence of pathologies may occur,” the researchers wrote.
