Case history

Case history #1

A 54-year-old man presents with a 10-year history of hypertension that has been difficult to control with antihypertensive medicines. His symptoms include frequent headaches, nocturia (3-4 times per night), and lethargy. He has no other medical conditions or past medical history. Apart from a blood pressure (BP) of 160/96 mmHg, findings on physical examination are unremarkable. Plasma electrolytes are normal.

Case history #2

A 28-year-old woman presents with a 2-year history of hypertension, associated with nocturia (4-5 times per night), polyuria, palpitations, limb paraesthesias, lethargy, and generalised muscle weakness. There is no other past medical history. Physical examination is unremarkable apart from a BP of 160/100 mmHg, global hyporeflexia, and weak muscles. Plasma potassium is 2.2 mmol/L (2.2 mEq/L), bicarbonate is 34 mmol/L (34 mEq/L), and serum creatinine is normal.

Other presentations

Hypertension in primary aldosteronism (PA) may be mild or severe and is rarely malignant.​[18] BP levels vary widely among patients with either aldosterone-producing adenoma or bilateral adrenal hyperplasia, and cannot be used to distinguish these subtypes.[19] In familial hyperaldosteronism type I (FH-I), hypertension is often delayed, especially in females, but can be of early onset and severe enough to cause early death, usually from haemorrhagic stroke.[20][21]​ Family screening in FH-I and families with PA of uncertain genetic aetiology has revealed highly diverse phenotypes with some patients normotensive, consistent with PA evolving through a pre-clinical phase.[4][13][21][22][23][24][25]​ Less than one quarter of patients diagnosed with PA and less than half of those with aldosterone-producing adenoma are hypokalaemic.​[26][27]​ In these patients, PA is indistinguishable from essential hypertension unless renin and aldosterone are measured. When hypokalaemia does occur, it may be associated with nocturia, polyuria, muscle weakness, cramps, paraesthesias, and/or palpitations. Nocturia is frequent even in the absence of hypokalaemia. Other common symptoms among either normokalaemic or hyperaemic patients include headaches, lethargy, mood alterations (including irritability, anxiety, or depression), and impaired mental concentration. During pregnancy, hypertension and symptoms may improve. This is thought to be due to the anti-mineralocorticoid effects of high circulating levels of placental progesterone, which antagonise aldosterone action at the mineralocorticoid receptor.

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