J Endocrinol Metab

Journal of Endocrinology and Metabolism, ISSN 1923-2861 print, 1923-287X online, Open Access

Article copyright, the authors; Journal compilation copyright, J Endocrinol Metab and Elmer Press Inc

Journal website http://www.jofem.org

Case Report

Volume 2, Number 6, December 2012, pages 235-243

Primary Hyperaldosteronism: Pitfalls in the Diagnosis and a not so Peculiar Evolution - Case Report

Figure 1. Abdominal CT scan. (a) 1999 - a small nodular lesion around 1 cm is noted in the left adrenal gland; no abnormalities were found regarding the right adrenal gland. (b) 2001 - a nodular lesion hypodense with 15 mm maximal diameter, is noted in the right adrenal gland, which is not apparent in the previous scan; no apparent lesions were found regarding the left adrenal gland.

Figure 2. ¹³¹I Norcholesterol Scintigraphic examination. (a) 1999 - images were obtained at the 3rd, 5th and 8th day; slight hyperfixation is found over both the adrenals. (b) 2007 - images were obtained at the 3rd and 7th day; clear hyperfixation above the upper pole of the right kidney more evident at the 7th day.

**Table 1.** Saline Suppression Test (NaCl 0.9%, 2,000 mL, ev, Over 4 h)
	0 h	2 h	4 h	RV
Renin and aldosterone were measured by radioimmunoassay (Diagnostic Products Corporation, Los Angeles); intra- and interassay coefficients of variation were less than 10%. Baseline decubitus (D) reference values (RV) are presented.
Renin (µU/mL)	1	0.8	0.7	(D - 1 - 20µU/mL)
Aldosterone (pg/mL)	310	150	226	(D - 10 - 160 pg/mL)

Table 1. Saline Suppression Test (NaCl 0.9%, 2,000 mL, ev, Over 4 h)

0 h

2 h

4 h

Renin and aldosterone were measured by radioimmunoassay (Diagnostic Products Corporation, Los Angeles); intra- and interassay coefficients of variation were less than 10%. Baseline decubitus (D) reference values (RV) are presented.

Renin (µU/mL)

0.8

0.7

(D - 1 - 20µU/mL)

Aldosterone (pg/mL)

310

150

226

(D - 10 - 160 pg/mL)

**Table 2.** Ambulatory Testing (4 h Brisk Walking)
	Before	After	RV
Reference values (RV) are present for the decubitus (D) and standing (S) position.
Renin (µU/mL)	1	2	(D -1 - 20 µU/mL) (S - 2 - 60 µU/mL)
Aldosterone (pg/mL)	280	367	(D - 10 - 160 pg/mL) (S - 40 - 310 pg/mL)

Table 2. Ambulatory Testing (4 h Brisk Walking)

Before

After

Reference values (RV) are present for the decubitus (D) and standing (S) position.

Renin (µU/mL)

(D -1 - 20 µU/mL) (S - 2 - 60 µU/mL)

Aldosterone (pg/mL)

280

367

(D - 10 - 160 pg/mL) (S - 40 - 310 pg/mL)

**Table 3.** Tetracosactide Test (250 µg ACTH1-24, ev)
	0 min	30 min	60 min	RV
Cortisol was measured by chemiluminoscence immunoassay and 17-hydroxyprogesterone ad 11-deoxi-cortisol were measured by radioimmunoassay (Diagnostic Products Corporation, Los Angeles). Reference values (RV) are presented at 8h am, or in the follicular phase (FF).
Cortisol (µg/dL)	19	58	56	(8h am - 4 - 23 µg/dL)
17-hydroxiprogesterone (ng/mL)	3	10	7	(FF - 0.2 - 1.8 ng/mL)
11-deoxi-cortisol (ng/mL)	1	4	4	(< 8 ng/mL)
Renin (µU/mL)	1	1	2	(1 - 20µU/mL)
Aldosterone (pg/mL)	210	1,030	80	(10 - 160 pg/mL)

Table 3. Tetracosactide Test (250 µg ACTH1-24, ev)

0 min

30 min

60 min

Cortisol was measured by chemiluminoscence immunoassay and 17-hydroxyprogesterone ad 11-deoxi-cortisol were measured by radioimmunoassay (Diagnostic Products Corporation, Los Angeles). Reference values (RV) are presented at 8h am, or in the follicular phase (FF).

Cortisol (µg/dL)

(8h am - 4 - 23 µg/dL)

17-hydroxiprogesterone (ng/mL)

(FF - 0.2 - 1.8 ng/mL)

11-deoxi-cortisol (ng/mL)

(< 8 ng/mL)

Renin (µU/mL)

(1 - 20µU/mL)

Aldosterone (pg/mL)

210

1,030

(10 - 160 pg/mL)

**Table 4.** Saline Suppression Test (NaCl 0.9%, 2,000 mL, ev, Over 4 h)
	0 h	2 h	4 h	RV
Renin (µU/mL)	0.7	0.9	0.5	(1 - 20 µU/mL)
Aldosterone (pg/mL)	350	320	560	(10 - 160 pg/mL)

Table 4. Saline Suppression Test (NaCl 0.9%, 2,000 mL, ev, Over 4 h)

0 h

2 h

4 h

Renin (µU/mL)

0.7

0.9

0.5

(1 - 20 µU/mL)

Aldosterone (pg/mL)

350

320

560

(10 - 160 pg/mL)

**Table 5.** Ambulatory Testing (4 h Brisk Walking)
	Before	After	RV
Renin (µU/mL)	0.7	0.6	(D -1 - 20 µU/mL) (S – 2 - 60 µU/mL)
Aldosterone (pg/mL)	280	580	(D - 10 - 160 pg/mL) (S - 40 - 310 pg/mL)

Table 5. Ambulatory Testing (4 h Brisk Walking)

Before

After

Renin (µU/mL)

0.7

0.6

(D -1 - 20 µU/mL) (S – 2 - 60 µU/mL)

Aldosterone (pg/mL)

280

580

(D - 10 - 160 pg/mL) (S - 40 - 310 pg/mL)

**Table 6.** Saline Suppression Test (2 L Normosaline Infused ev Over 4 h)
	0 h	2 h	4 h
Renin (µU/mL)	0.6	0.7	0.7	(1 - 20 µU/mL)
Aldosterone (pg/mL)	716	267	219	(10 - 160 pg/mL)

Table 6. Saline Suppression Test (2 L Normosaline Infused ev Over 4 h)

0 h

2 h

4 h

Renin (µU/mL)

0.6

0.7

(1 - 20 µU/mL)

Aldosterone (pg/mL)

716

267

219

(10 - 160 pg/mL)

**Table 7.** Ambulatory Test (4 h of Brisk Walking)
	0 h	4 h	RV
Renin (µU/Ml)	0.5	0.4	(D -1 - 20 µU/mL) (S - 2 - 60 µU/mL)
Aldosterone (pg/mL)	631	1,000	(D - 10 - 160 pg/mL) (S - 40 - 310 pg/mL)

Table 7. Ambulatory Test (4 h of Brisk Walking)

0 h

4 h

Renin (µU/Ml)

0.5

0.4

(D -1 - 20 µU/mL) (S - 2 - 60 µU/mL)

Aldosterone (pg/mL)

631

1,000

(D - 10 - 160 pg/mL) (S - 40 - 310 pg/mL)