A 28-yr-old college lecturer from interior southern India, had complaints of polyuria since November 2001. Polyuria was noticed only in recumbent position irrespective of the time of the day. She first consulted an urologist, who diagnosed nephrolithiasis for which she underwent extracorporeal short wave Lithotripsy (ESWL). At that time she was detected to have a blood pressure of 170/90 mmHg and also noted to have spasms of the upper limb while recording the blood pressure. She was examined by the local physician who diagnosed hypertension and started her on amlodipine. Blood chemistries done at that time including calcium and phosphorus were normal and potassium was 3.56 mM/L (3.5-5). Her urinary symptoms continued to persist despite treatment. In 2003 she became pregnant and carried through the pregnancy well until 32 weeks. Pregnancy had to be terminated with a caesarean section when it became increasingly difficult to control her blood pressure. After delivery she started having severe cramps in both upper and lower limbs. An endocrinology consultation was sought in 2004 for recurrent cramps, a thorough work up was done and results are shown in .
Biochemical investigations done in 2004 for work up of hypocalcemia done elsewhere (values in parenthesis indicate normal range)
Since no obvious cause for hypocalcemia was found, an intrinsic calcium absorption defect was suspected and patient was advised six grams of calcium orally, without any symptomatic improvement. In the subsequent months, atenolol, losartan and prazosin were all added, at different times, in order to control the blood pressure.
She was first seen in our institution in April 2005 with the above described complaints in the urology department. She had a significant weight loss of 12 kg in the past year. She had never smoked cigarettes or consumed alcohol. None of the family members were hypertensive or had adrenal or other endocrine tumors.
Her physical examination revealed a blood pressure of 150/ 90 mmHg, without any postural variation. Carpal spasm was noticed when blood pressure was being taken. Pulse rate was 80/min and respiratory rate was 18/min. She was 165 cm tall and weighed 64 kg. Systemic examination was unremarkable. A complete urological work up including plain abdominal radiography, intra venous pyelography, micturating cystourethrogram were all done which failed to explain her symptoms. Simultaneously she was being worked up for secondary causes of hypertension. The results of the investigations are shown in .
Results from biochemical investigations in our institution during admissions
Sonography of the abdomen had revealed multiple hyperechoeic foci with shadowing in the right kidney, mild hepatomegaly measuring 15 cm with normal echotexture and a well defined hypoechoeic lesion measuring about 3×3×3 cm in the left suprarenal region. Bilateral renal Doppler showed few renal indices in the upper limit of the normal. Hence renal artery stenosis was ruled out with renal angiogram. Serum aldosterone in standing position was elevated at 318.94 ng/L (5-41). Electrocardiography showed left ventricular hypertrophy with strain pattern while 2D Echocardiography revealed slight enlargement of the left ventricular chamber with a normal ejection fraction and mild Mitral regurgitation. A computed tomography scan of abdomen confirmed a well defined exophytic mass lesion (3×2.8×2.8 cm) from the left adrenal mass ().
Fig. 1 (A) Plain computed tomography image of the abdomen showing a mass measuring 3×3×3 cm in the supra renal region on the left side (arrow). (B) Contrast CT of the same region showing a non enhancing nature of the mass lesion in the same area. (more ...)
Patient was optimized for surgery with multiple antihy-pertensive drugs including spironolactone, atenolol and amlodipine with which stable blood pressure control was achieved. She underwent left adrenalectomy under general anesthesia and the exophytic mass was resected. Patient tolerated the procedure well and made a good post operative recovery. Operative specimen and histopathology was consistent with adrenal adenoma (, ).
Gross operative specimen showing a 3×3 cm exophytic adrenal mass excised from the left suprarenal area.
Microscopy after HE stain showing rounded lipid rich clear cells resembling those of normal zona fasciculate.
Her blood pressure started normalizing and her anti-hypertensive medications were gradually tapered. At follow-up after 6 weeks patient was off antihypertensive medication and blood pressure was normal. Her repeat biochemistries revealed potassium of 4.3 meq/L and calcium of 9.7 mg/dL (8.7-10.2). She did not have cramps and had regained 12 kg. At one year follow-up, she has regained her pre-morbid weight and continues to be normotensive and symptom free.