title: Difficult-to-control hypertension due to bilateral aldosterone-producing adrenocortical microadenomas associated with a cortisol-producing adrenal macroadenoma.
abstract: The patient was a 54-year-old woman who developed a right adrenal tumour, Cushingoid features, elevated levels of cortisol that were not suppressed by 1 nor 8 mg of dexamethasone, and suppression of adrenocorticotropin (ACTH) during treatment for severe hypertension. Computed tomography (CT) revealed a right adrenal tumour and an atrophic left adrenal gland. In addition, elevated plasma aldosterone concentration (PAC) and suppressed plasma renin activity (PRA) with an aldosterone-to-renin ratio of 128 (ng per 100 ml per ng ml⁻¹ h⁻¹) suggested aldosterone excess. Urinary excretion of aldosterone was relatively high, and the captopril and rapid ACTH tests resulted in no response of PRA and exaggerated increase in PAC, respectively. ACTH-loaded adrenal venous sampling showed bilateral excess of aldosterone with right predominance of cortisol. Right laparoscopic partial adrenalectomy (ADX) and immunohistochemical analysis showed both a cortisol-producing adenoma and an aldosterone-producing microadenoma (microAPA) within the attached adrenal, which had not been detected by CT preoperatively. After the right partial ADX, her blood pressure, aldosterone level and suppressed PRA remained unchanged. Subsequently, laparoscopic total left ADX was performed. Two microAPAs with paradoxical hyperplasia were revealed within the apparently atrophic left adrenal gland. Soon after the second surgery, her blood pressure normalized without requiring any anti-hypertensive medication.
authors.affiliation: Division of Nephrology, Endocrinology, and Vascular Medicine, Department of Medicine, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan.
authors.forename: R
authors.initials: R
authors.lastname: Morimoto
authors.forename: M
authors.initials: M
authors.lastname: Kudo
authors.forename: O
authors.initials: O
authors.lastname: Murakami
authors.forename: K
authors.initials: K
authors.lastname: Takase
authors.forename: S
authors.initials: S
authors.lastname: Ishidoya
authors.forename: Y
authors.initials: Y
authors.lastname: Nakamura
authors.forename: T
authors.initials: T
authors.lastname: Ishibashi
authors.forename: S
authors.initials: S
authors.lastname: Takahashi
authors.forename: Y
authors.initials: Y
authors.lastname: Arai
authors.forename: T
authors.initials: T
authors.lastname: Suzuki
authors.forename: H
authors.initials: H
authors.lastname: Sasano
authors.forename: S
authors.initials: S
authors.lastname: Ito
authors.forename: F
authors.initials: F
authors.lastname: Satoh
mesh_terms: D000302:Adrenal Cortex / Q000000981:diagnostic imaging / Q000473:pathology; D000306:Adrenal Cortex Neoplasms / Q000097:blood / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery; D000315:Adrenalectomy; D018246:Adrenocortical Adenoma / Q000097:blood / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery; D000450:Aldosterone / Q000097:blood*; D003480:Cushing Syndrome / Q000097:blood / Q000000981:diagnostic imaging / Q000209:etiology / Q000628:therapy; D005260:Female; D006801:Humans; D006854:Hydrocortisone / Q000097:blood*; D006929:Hyperaldosteronism / Q000097:blood / Q000000981:diagnostic imaging / Q000209:etiology / Q000628:therapy; D006973:Hypertension / Q000097:blood / Q000209:etiology* / Q000503:physiopathology / Q000628:therapy; D008875:Middle Aged; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
chemical_list: D000450:Aldosterone; D006854:Hydrocortisone
references.citation: J Renin Angiotensin Aldosterone Syst. 2008 Jun;9(2):103-6
references.pmid: 18584586
references.citation: Endocr J. 2007 Apr;54(2):287-93
references.pmid: 17379961
references.citation: Int J Urol. 2003 Oct;10(10):544-6
references.pmid: 14516402
references.citation: J Clin Endocrinol Metab. 2008 Sep;93(9):3266-81
references.pmid: 18552288
references.citation: Hypertens Res. 2006 Nov;29(11):883-9
references.pmid: 17345788
references.citation: Am J Hypertens. 2008 Nov;21(11):1269-72
references.pmid: 18772856
references.citation: Endocr J. 2001 Feb;48(1):103-11
references.pmid: 11403095
references.citation: Hypertens Res. 2003 Aug;26(8):663-8
references.pmid: 14567506
references.citation: Eur J Endocrinol. 2001 Mar;144(3):199-206
references.pmid: 11248736
references.citation: Clin Exp Pharmacol Physiol. 1995 Jun-Jul;22(6-7):460-2
references.pmid: 8582103
references.citation: Trends Endocrinol Metab. 2008 Apr;19(3):88-90
references.pmid: 18314347
references.citation: Am J Surg Pathol. 1989 Mar;13(3):202-6
references.pmid: 2919718
references.citation: Hypertens Res. 2004 Mar;27(3):193-202
references.pmid: 15080378
references.citation: Eur J Endocrinol. 2009 Mar;160(3):443-51
references.pmid: 19131502
references.citation: Am J Surg Pathol. 1984 Mar;8(3):163-9
references.pmid: 6703192
references.citation: Clin Endocrinol (Oxf). 1997 May;46(5):619-26
references.pmid: 9231058
references.citation: J Lab Clin Med. 1976 Aug;88(2):261-70
references.pmid: 182890
references.citation: Endocr J. 2009;56(3):495-502
references.pmid: 19270420
references.citation: Metabolism. 2002 Mar;51(3):350-5
references.pmid: 11887172
references.citation: Intern Med. 2008;47(1):37-42
references.pmid: 18176003
references.citation: J Clin Endocrinol Metab. 1969 Feb;29(2):239-50
references.pmid: 4303579
references.citation: Clin Exp Nephrol. 2008 Oct;12(5):382-387
references.pmid: 18543063
references.citation: Am J Med. 1972 Nov;53(5):627-37
references.pmid: 4342887
references.citation: J Clin Endocrinol Metab. 2003 May;88(5):1994-8
references.pmid: 12727943
references.citation: Hypertens Res. 2007 Apr;30(4):367-73
references.pmid: 17541216
references.citation: Hypertens Res. 2007 Nov;30(11):1083-95
references.pmid: 18250558
references.citation: J Clin Invest. 1973 Sep;52(9):2272-7
references.pmid: 4353776
references.citation: Horm Res. 1997;47(4-6):273-8
references.pmid: 9167964
references.citation: J Endocrinol. 1998 Mar;156(3):415-23
references.pmid: 9582497
references.citation: J Clin Endocrinol Metab. 1973 Nov;37(5):765-75
references.pmid: 4356136
references.citation: J Endocrinol. 2007 Oct;195(1):39-48
references.pmid: 17911395
references.citation: J Clin Endocrinol Metab. 1968 Jul;28(7):1006-13
references.pmid: 4298942
references.citation: J Clin Endocrinol Metab. 1976 Jul;43(1):115-31
references.pmid: 947931
references.citation: Clin Exp Nephrol. 2006 Jun;10(2):127-30
references.pmid: 16791399
references.citation: Clin Endocrinol (Oxf). 1974 Jan;3(1):41-8
references.pmid: 4366076
references.citation: Hypertens Res. 2008 Aug;31(8):1669-75
references.pmid: 18971543
references.citation: J Clin Endocrinol Metab. 1978 Apr;46(4):552-60
references.pmid: 225341
references.citation: Hypertens Res. 2001 Nov;24(6):723-6
references.pmid: 11768734
references.citation: Endocr J. 1994 Oct;41(5):471-82
references.pmid: 7889106