Case 39 Index
As further work-up is being arranged, what is the best choice to manage this patient’s blood pressure?
Correct! An aldosterone receptor antagonist is the most appropriate choice in this case.
While amiloride may work effectively in this case for blood pressure and hypokalemia, there is a better option to directly antagonize the culprit hormone effect.
A beta blocker is not the best choice in this case. There is a better option here to directly antagonize the culprit hormone effect.
This diuretic will be unlikely to have a strong blood pressure effect, and it may actually worsen this patient’s hypokalemia. Try something else!
Pick again! This medication may help somewhat to reduce blood pressure, but it will do nothing for hypokalemia. There is a better option.
This medication will inhibit carbonic anhydrase in the proximal tubule. Our patient’s metabolic alkalosis is likely driven by a more distal issue. Try something else!
An adrenal computed tomography (CT) scan is performed.
Image courtesy of: http://www.endocrinesurgery.net.au/conns-diagnosis/
The diagnosis of a left unilateral adrenal adenoma is made.
Which of the following is the next best step?
Adrenal vein sampling (AVS)
Correct! It is the standard to confirm this left adrenal adenoma as the active source of aldosterone excretion. A size between 1-2cm in a young patient is very convincing, but studies have shown imaging was concordant with AVS in as low as only 60% of cases, and reliance on imaging alone can lead to the wrong adrenal gland being removed! In this case, AVS lateralizes the excess aldosterone excretion to the left side.
Once confirmation of an active, unilateral aldosterone-secreting adrenal adenoma is made, this patient is a good candidate for surgical adrenalectomy. Laparoscopic surgery is preferred to open due to shorter hospital stays and fewer complications. However, best to confirm with another test before going to the OR.
Mineralocorticoid receptor antagonists (MRA) alone
MRA therapy with a medication such as spironolactone will be an effective management strategy. However, this young patient with a unilateral adrenal adenoma could benefit from more definitive therapy.
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Case 39 Index
Case 39 Introduction
Case 39 Physical Exam
Case 39 Diagnostic Testing