The Invisible Evil Twin of an Adrenal Adenoma

2019 ◽  
Vol 4 (1) ◽  
pp. 58
Author(s):  
Aimi Fadilah Mohamad ◽  
Fatimah Zaherah Mohamed Shah ◽  
Nur Aisyah Zainordin ◽  
Ur 'Aini Eddy Warman ◽  
Nazimah Ab Mumin ◽  
...  
Keyword(s):  
Adrenal Glands ◽  
Adrenal Adenoma ◽  
Definitive Diagnosis ◽  
Dynamic Tests ◽  
Venous Sampling ◽  
Aldosterone Secretion ◽  
Aldosterone Level ◽  
Suppression Test ◽  
The Right ◽  
Secondary Causes

Primary aldosteronism (PA) causes a persistently elevated blood pressure (BP) due to excessive release of the hormone aldosterone from the adrenal glands. Classically, it is called Conn’s syndrome and is described as the triad of hypertension and hypokalemia with the presence of unilateral adrenal adenoma. It can be cured with surgical resection of the aldosterone-secreting adenoma leading to resolution of hypertension, hypokalemia and increased cardiovascular risk associated with hyperaldosteronism. We present a case of a man with previous ischemic heart disease (IHD) who presented with resistant hypertension. Investigations for secondary causes of hypertension revealed an elevated aldosterone level and saline suppression test confirmed the diagnosis of PA. Radiological examination revealed a left adrenal adenoma and a normal right adrenal gland. However, adrenal venous sampling showed lateralization of aldosterone secretion towards the right. He subsequently underwent a laparoscopic right adrenalectomy which improved his BP control promptly. This case highlights the importance of recognizing the need to investigate for secondary causes of hypertension. It also underscores the importance of dynamic tests, which may not be easily accessible to most clinicians but should pursue, to allow a definitive diagnosis and effective treatment.

scholarly journals SUN-202 Is a “Failed” Adrenal Venous Sampling Useful for Surgical Decision Making in Primary Hyperaldosteronism?

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Rania El Mais ◽  
Runa Acharya
Keyword(s):  
Adrenal Adenoma ◽  
Plasma Aldosterone ◽  
Primary Hyperaldosteronism ◽  
Adrenal Vein ◽  
Adrenal Venous Sampling ◽  
Uncontrolled Hypertension ◽  
Venous Sampling ◽  
Plasma Aldosterone Concentration ◽  
Salt Loading ◽  
The Right

Abstract Background Adrenal venous sampling (AVS) is important in differentiating unilateral vs bilateral primary hyperaldosteronism. A limitation is the difficult cannulation of the right adrenal vein (RAV). A study in 2016(1) investigated the usefulness of AVS with failed right sided cannulation. The investigators calculated the ratios of plasma aldosterone and cortisol in the periphery (IVC) and in the left adrenal vein (LAV), then corrected the aldosterone/cortisol ratio of the LAV for that of the IVC with the following equation: LAV/ IVC = [aldosterone in LAV/cortisol in LAV] / [aldosterone in IVC/ cortisol in IVC]. A LAV/IVC ratio ≥5.5 and ≤0.5 predicted unilateral aldosterone hypersecretion on left and right side respectively with a 100% specificity and positive predictive value. Clinical case We present a case of a 51-year-old patient with primary hyperaldosteronism and a failed right sided cannulation. Patient presented with uncontrolled hypertension of 10 years and hypokalemia. His blood pressure (BP) was 190/100 on amlodipine, lisinopril, atenolol, hydralazine and spironolactone. Screening labs obtained off spironolactone and atenolol showed: Aldosterone 18.5ng/dl(0-30), renin 0.215ng/ml(0.167-5.738), plasma aldosterone concentration (PAC)/ plasma renin concentration (PRC) 86. CT abdomen showed a 1.2cmX1cm left adrenal adenoma. A 24-hour urine collection without salt loading showed an aldosterone of 43.46 microg/L (0-19). He underwent an AVS with a failed RAV cannulation with the following results: IVC: cortisol=17.2 microg/dl, aldosterone= 8.9ng/dl, aldosterone/cortisol= 0.52 LAV: cortisol=420, aldosterone=2860, aldosterone/cortisol=6.8. Partial left adrenalectomy was performed. Pathology showed a benign adenoma. Although his BP initially improved, over several weeks, his BP was high again, and he had a recurrence of hypokalemia. A repeat PAC/PRC of 80 confirmed persistent hyperaldosteronism. He refused further interventions. Eplerenone was added resulting in BP control. Conclusion Based on the above study, his LAV/IVC of 13 predicts the source to be the left adrenal gland. However, this ratio did not apply in our patient and should be utilized carefully. References: 1.Pasternak JD, Epelboym I, Seiser N, Wingo M, Herman M, Cowan V, et al. Diagnostic utility of data from adrenal venous sampling for primary aldosteronism despite failed cannulation of the right adrenal vein. Surgery. 2016;159(1):267-73.

scholarly journals Intraorbital wooden foreign body detected by computed tomography and magnetic resonance imaging

2016 ◽  
Vol 30 (1) ◽  
pp. 88-91 ◽  
Author(s):  
Alfredo Di Gaeta ◽  
Francesco Giurazza ◽  
Eugenio Capobianco ◽  
Alvaro Diano ◽  
Mario Muto
Keyword(s):  
Computed Tomography ◽  
Foreign Body ◽  
Magnetic Resonance ◽  
Delayed Diagnosis ◽  
Clinical History ◽  
Definitive Diagnosis ◽  
Double Vision ◽  
Resonance Imaging ◽  
Wooden Foreign Body ◽  
The Right

To identify and localize an intraorbital wooden foreign body is often a challenging radiological issue; delayed diagnosis can lead to serious adverse complications. Preliminary radiographic interpretations are often integrated with computed tomography and magnetic resonance, which play a crucial role in reaching the correct definitive diagnosis. We report on a 40 years old male complaining of pain in the right orbit referred to our hospital for evaluation of eyeball pain and double vision with an unclear clinical history. Computed tomography and magnetic resonance scans supposed the presence of an abscess caused by a foreign intraorbital body, confirmed by surgical findings.

Adrenal Hypertension

2017 ◽  
Author(s):  
Naomi D.L. Fisher ◽  
Gail K Adler
Keyword(s):  
Myocardial Infarction ◽  
Adrenal Glands ◽  
Cushing Syndrome ◽  
Rare Tumor ◽  
Cushing Disease ◽  
Increased Risk ◽  
Aldosterone Production ◽  
Artery Disease ◽  
Secondary Causes ◽  
Adrenal Hypertension

The secondary causes of hypertension are associated with the excess of the principal hormones produced by the adrenal glands: cortisol, epinephrine, and aldosterone. Excess aldosterone production is recognized as primary hyperaldosteronism, or primary aldosteronism (PA). Individuals with PA are at increased risk for a variety of disorders, including atrial fibrillation, coronary artery disease, myocardial infarction, and stroke. Pheochromocytoma is a very rare tumor (accounting for fewer than one in 10,000 hypertension cases) and is marked by high secretions of catecholamines, mostly epinephrine as well as norepinephrine. Cushing disease and Cushing syndrome are addressed in a separate review. This review contains 5 highly rendered figures, 4 tables, and 39 references.

scholarly journals A case of Williams syndrome with suspected coexisting ectopic aldosterone-producing tumor in the liver

2020 ◽  
Vol 2020 ◽  
Author(s):  
Shuhei Baba ◽  
Arina Miyoshi ◽  
Shinji Obara ◽  
Hiroaki Usubuchi ◽  
Satoshi Terae ◽  
...  
Keyword(s):  
Williams Syndrome ◽  
Primary Aldosteronism ◽  
High Plasma ◽  
Plasma Aldosterone ◽  
Adrenal Tumors ◽  
Venous Sampling ◽  
Plasma Aldosterone Concentration ◽  
Adrenal Rest Tumor ◽  
Adrenal Rest ◽  
The Right

Summary A 31-year-old man with Williams syndrome (WS) was referred to our hospital because of a 9-year history of hypertension, hypokalemia, and high plasma aldosterone concentration to renin activity ratio. A diagnosis of primary aldosteronism (PA) was clinically confirmed but an abdominal CT scan showed no abnormal findings in his adrenal glands. However, a 13-mm hypervascular tumor in the posterosuperior segment of the right hepatic lobe was detected. Adrenal venous sampling (AVS) subsequently revealed the presence of an extended tributary of the right adrenal vein to the liver surrounding the tumor. Segmental AVS further demonstrated a high plasma aldosterone concentration (PAC) in the right superior tributary vein draining the tumor. Laparoscopic partial hepatectomy was performed. The resected tumor histologically separated from the liver was composed of clear cells, immunohistochemically positive for aldesterone synthase (CYP11B2), and subsequently diagnosed as aldosterone-producing adrenal adenoma. After surgery, his blood pressure, serum potassium level, plasma renin activity and PAC were normalized. To the best of our knowledge, this is the first report of WS associated with PA. WS harbors a high prevalence of hypertension and therefore PA should be considered when managing the patients with WS and hypertension. In this case, the CT findings alone could not differentiate the adrenal rest tumor. Our case, therefore, highlights the usefulness of segmental AVS to distinguish adrenal tumors from hepatic adrenal rest tumors. Learning points: Williams syndrome (WS) is a rare genetic disorder, characterized by a constellation of medical and cognitive findings, with a hallmark feature of generalized arteriopathy presenting as stenoses of elastic arteries and hypertension. WS is a disease with a high frequency of hypertension but the renin-aldosterone system in WS cases has not been studied at all. If a patient with WS had hypertension and severe hypokalemia, low PRA and high ARR, the coexistence of primary aldosteronism (PA) should be considered. Adrenal rest tumors are thought to arise from aberrant adrenal tissues and are a rare cause of PA. Hepatic adrenal rest tumor (HART) should be considered in the differential diagnosis when detecting a mass in the right hepatic lobe. Segmental adrenal venous sampling could contribute to distinguish adrenal tumors from HART.

Biochemically silent phaeochromocytoma presenting with non-specific loin pain

2021 ◽  
Vol 14 (8) ◽  
pp. e244258
Author(s):  
Annalisa Montebello ◽  
Etienne Ceci Bonello ◽  
Miriam Giordano Imbroll ◽  
Mark Gruppetta
Keyword(s):  
Adrenal Adenoma ◽  
Dexamethasone Suppression Test ◽  
Adrenal Lesion ◽  
Genetic Mutations ◽  
Large Size ◽  
History Of ◽  
Loin Pain ◽  
Suppression Test ◽  
Aldosterone To Renin Ratio ◽  
Dexamethasone Suppression

A 55-year-old woman presented with a 4-month history of right-sided non-specific loin pain and 6 kg weight loss. A CT scan of the abdomen and pelvis showed an incidental 4.5 cm right-sided adrenal lesion which was not typical of an adrenal adenoma. This was further confirmed on MRI of the adrenals. Biochemical investigations to investigate for a functional adrenal lesion included serum catecholamines and metanephrines, an aldosterone to renin ratio and an overnight dexamethasone suppression test. These were all negative. A laparoscopic adrenalectomy was performed in view of the large size of the lesion. Histology was consistent with a phaeochromocytoma, which confirmed the diagnosis of a non-secreting phaeochromocytoma. Non-secreting phaeochromocytomas are rare and usually found in patients with known genetic mutations. Adrenal lesions not related to any mutations similar to our case are even rarer and reported even less in the literature.

Primary B-Cell lymphoma of the mandible: a potentially difficult diagnosis

Dental Update ◽  
2019 ◽  
Vol 46 (7) ◽  
pp. 672-674
Author(s):  
Hudson King ◽  
Simon Rogers
Keyword(s):  
Case Report ◽  
B Cell ◽  
Cell Lymphoma ◽  
B Cell Lymphoma ◽  
Definitive Diagnosis ◽  
Lower Lip ◽  
Difficult Diagnosis ◽  
The Right ◽  
High Degree ◽  
Rare Diagnosis

There are many causes of a persistent unilateral numbness of the lower lip. A case report of a 34-year-old normally fit and well male, whose symptoms of numbness of the mandibular division of the right trigeminal nerve represented the rare diagnosis of a primary B-cell lymphoma of the mandible, is presented here. The patient's presentation and management, reasons for the difficulty in ascertaining a definitive diagnosis, as well as invaluable points to be reflected on from this case, are discussed. CPD/Clinical Relevance: Numbness should be treated with a high degree of suspicion, with urgent imaging, biopsy and specialist histopathology staining being carried out to exclude malignancy.

scholarly journals Adrenal Venous Sampling in Primary Aldosteronism: The Usefulness of Contralateral Suppression Index

2019 ◽  
Vol 2019 ◽  
pp. 1-4 ◽  
Author(s):  
Natalia Treistman ◽  
Aline Barbosa Moraes ◽  
Stéphanie Cozzolino ◽  
Patrícia de Fatima dos Santos Teixeira ◽  
Leonardo Vieira Neto
Keyword(s):  
Primary Aldosteronism ◽  
Vena Cava ◽  
Adrenal Vein ◽  
Adrenal Venous Sampling ◽  
Venous Sampling ◽  
Successful Cannulation ◽  
Contralateral Suppression ◽  
The Right ◽  
Cortisol Ratio ◽  
Suppression Index

Adrenal venous sampling (AVS) is the gold standard test to differentiate the unilateral from the bilateral form in patients with primary aldosteronism (PA) although it may be a difficult procedure, especially the successful cannulation of the right adrenal vein. In this report, we describe a 49-year-old female patient diagnosed with PA, after investigating resistant hypertension and refractory hypokalemia. Abdominal computed tomography scan revealed a 2.5 cm adenoma on the right adrenal vein. AVS was performed under cosyntropin infusion. Aldosterone and cortisol concentrations were obtained from the right and left adrenal veins and inferior vena cava (IVC). Cortisol on each adrenal vein divided by cortisol on IVC confirmed successful cannulation of the left side only, which makes it impossible to calculate the lateralization index (LI). From the data on the left adrenal vein and IVC, the aldosterone-to-cortisol ratio divided by the IVC aldosterone-to-cortisol ratio was less than 1.0, suggesting that the left adrenal vein was suppressed with the excess aldosterone originating from the contralateral side (contralateral suppression index (CSI)). Right adrenalectomy was performed; postoperative hypoaldosteronism was confirmed. This report highlights the importance of CSI obtained in AVS when technical difficulties occur making it impossible to obtain LI, which is most commonly used to decide between surgical and clinical management of PA.

scholarly journals A postmortem study on the weight of the human adrenal glands

1970 ◽  
Vol 9 (4) ◽  
pp. 204-207 ◽  
Author(s):  
Dilruba Siddiqua ◽  
Shamim Ara ◽  
Abu Sadat Mohammad Nurunnabi ◽  
Rukshana Ahmed ◽  
Ara Parven Hosne
Keyword(s):  
Adrenal Gland ◽  
Adrenal Glands ◽  
Medical Science ◽  
Age Groups ◽  
Cross Sectional ◽  
Medical College ◽  
Group A ◽  
Group B ◽  
The Right ◽  
Group D

Objective: A cross-sectional descriptive type of study was designed to find out the difference in weight of the right and left adrenal glands of Bangladeshi people in relation to age and to compare with the previous studies. Materials & Methods: The study was done in the Department of Anatomy, Dhaka Medical College, Dhaka from July 2008 to June 2009 and performed on 140 post mortem human adrenal glands collected from 70 unclaimed dead bodies which were in the morgue under examination in the Department of Forensic Medicine, Dhaka Medical College, Dhaka. The samples were divided into four age-groups including group A (11-20 years), group B (21-30 years), group C (31-40 years) & group D (41-60 years) and the weight of the adrenal glands were measured and recorded. Results: There was no difference found in weight in between the right and the left adrenal glands in any age group. For the right adrenal gland, the differences in weight between group A & group B and group A & group D were statistically significant (p<0.05). For the left adrenal gland, the differences in weight between group A & group D and group C & group D were statistically significant (p<0.05). Key words: Adrenal gland; weight of adrenal gland. DOI: 10.3329/bjms.v9i4.6686Bangladesh Journal of Medical Science Vol.09 No.4 July 2010 pp.204-207

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