ONE GLAND, MANY CHALLENGES: A CASE OF SECONDARY HYPERTENSION DUE TO ADENOMA IN A SINGLE ADRENAL GLAND

Objective: To present a complex case of resistant hypertension in a patient with a single adrenal gland harbouring an adenoma, highlighting the challenges in diagnosis and treatment when surgical intervention is not feasible, and the patient’s preferences limit therapeutic options. Design and method: This case involves a 72-year-old female with a 20-year history of severe refractory hypertension, dyslipidemia, and moderate renal dysfunction. The patient’s medical history includes a left adrenalectomy for an adrenal mass initially suspected to be pheochromocytoma or adrenal adenoma, a diagnosis later ruled out histopathologically. Upon admission, the patient was on four antihypertensives, and ambulatory blood pressure monitoring confirmed significantly elevated diurnal and nocturnal values, with a reverse-dipper profile. Comprehensive evaluation, including renal artery Doppler, renal ultrasound, laboratory testing, and polysomnography, ruled out renovascular, renoparenchymal, and sleep apnea-related causes. CT imaging identified a 33/14 mm lesion on the right adrenal gland, suggestive of an adrenal adenoma. Results: Despite the high probability of adrenal adenoma-related hyperaldosteronism, surgical intervention was deemed unsuitable due to the patient’s single remaining adrenal gland. Initial medical therapy included a thiazide-like diuretic combined with an ACE inhibitor and calcium channel blocker in a single pill, and a mineralocorticoid receptor antagonist (spironolactone). However, the patient developed a dry cough (associated with the ACE inhibitor) and moderate hyperkalemia, leading to the discontinuation of spironolactone. Importantly, the patient declined eplerenone as an alternative. Therapy was adjusted to include a sartan, thiazide-like diuretic, calcium channel blocker, beta-blocker, and rilmenidine. The aldosterone-renin ratio, measured after therapy adjustment, confirmed the diagnosis of hyperaldosteronism. Conclusions: This case illustrates the challenges in managing resistant hypertension and hyperaldosteronism in a patient with an unique adrenal gland and an adenoma. The inability to pursue surgical options, coupled with treatment-related adverse effects and the patient’s refusal of eplerenone, underscores the importance of individualized medical management and shared decision-making.