Primary Hyperaldosteronism Presenting Clinically as Classic Pheochromocytoma

Introduction: Primary hyperaldosteronism is a rare cause of hypertension, with the reported incidence between hypertensive population estimated to be 0.46% to 1%. Surgical adrenalectomy is a preferred treatment for patients who wish to achieve long term cure and who are surgical candidates. Here we present a case of primary hyperaldosteronism that presented with clinical symptoms of pheochromocytoma. Case Description: A 48 year old lady was seen in the clinic for poorly controlled hypertension. Therapy at the time included irbesartan 300mg daily, nebivolol 20mg daily, amlodipine 10mg daily and hydralazine 10mg three times daily. She was also found to have recurrent hypokalemia. Serum workup was revealing of suppressed renin with elevated aldosterone. Imaging included CT adrenal that showed 1.1 cm left adrenal nodule. Patient was diagnosed with hyperaldosteronism on serological workup confirmed with salt loading test and adrenal vein sampling revealed lateralization to the left with ratio of 6.9. While undergoing her work up, patient was experiencing a constellation of constitutional symptoms including profuse sweating, palpitations, impending sense of doom, flushing, and headaches. These symptoms were life altering and severe in nature requiring recurrent evaluations to the emergency department as they were associated with acute worsening of her blood pressure. Metanephrines were tested numerous times and were non-revealing; with highest serum metanephrines of 41 pg/mL, normetanephrines of 125 pg/ml, 24-hour urine total metanephrines of 597 ug/24hr and fractionated metanephrines all within normal values. Patient eventually underwent surgical laparoscopic left lateral transabdominal adrenalectomy. Pathology showed benign adrenal cortical proliferation consistent with adrenal cortical adenoma. Symptomatically the patient’s constitutional symptoms resolved following adrenalectomy, and her medically refractory hypertension improved to be controlled with a single agent. Discussion: Primary hyperaldosteronism is a well described cause of hypertension and suspicion should be high in patients with resistant hypertension in addition to recurrent hypokalemia. Symptoms of profuse sweating, palpitations and impending sense of doom are often associated with pheochromocytomas which can also result in hypertension. This case demonstrates how variability can exist in symptomatic burden.