Incidental but Significant: Unmasking Adrenal Adenoma Presenting as Hypokalemia

Introduction: Adrenal adenomas are usually incidental findings and can be nonfunctional or functional. The most frequent presentation is hypertension and Hypokalemia. Severe Hypokalemia with metabolic alkalosis and Rhabdomyolysis is extremely uncommon and can be life-threatening. Case Description: A 52-year-old male with PMH of Hypertension since early 30s came in with an acute onset of myalgia and muscle weakness. Initial labs showed severe Hypokalemia (serum K 1.6 mmol/L), increased bicarbonate (38.5 mmol/L), and highly elevated creatine kinase (6934 U/L), U/A- Blood 2+ RBC-3-10(microscopic hematuria), in consistent with rhabdomyolysis. EKG revealed U waves in keeping with the severity of Hypokalemia. Further Imaging with contrast-enhanced CT abdomen demonstrated a 2.0 x 1.7 cm well-defined nodule in the left adrenal gland, suggestive of non-lipid-rich adrenal adenoma. This raised concern for a functional adenoma. Though renin and aldosterone reports were pending, the patient was empirically treated with potassium repletion, aldosterone antagonists (spironolactone), and blood pressure control with an angiotensin receptor blocker (losartan). There was persistence in EKG alterations despite partial correction of electrolytes (K-2.4). Discussion: This case discusses an emphasis on the need to evaluate primary hyperaldosteronism in patients with unexplained severe hypokalemia, metabolic alkalosis, and rhabdomyolysis. Early suspicion, laboratory analysis, and imaging are needed for diagnosis. Early treatment with mineralocorticoid receptor antagonists can avoid complications, although final treatment may be surgical resection. High suspicion should be kept in mind by clinicians so that no delays in management are made, particularly in patients presenting with long-standing hypertension and recurrent electrolyte disturbances.