How the algorithms can change during the COVID-19 pandemic: A case of primary hyperaldosteronism

INTRODUCTION: Primary hyperaldosteronism (PA) is an important reason of secondary endocrine hypertension. The etiology is either an aldosterone producing adenoma or bilateral adrenal hyperplasia in 90% of cases. The diagnosis is based on specific algorithms starting with screening the population at risk and continues with confirmatory testing of positive resulted individuals. According to current recommendations, adrenal vein sampling (AVS) and imaging should both be used to classify the subtypes of PA; but during the COVID-19 pandemic, the algorithms may have to be changed. Here, we present a case diagnosed with PA and successfully treated during pandemic. CLINICAL CASE: A fifty-one-year-old male patient was referred to our department from internal medicine clinic with hypertension and hypokalemia. He was hypertensive since 30 years old, but he had no history or clinical symptoms of hypokalemia or hypertension associated organ injury. His blood pressures (BP) were under control with 10 mg of amlodipine. But for the last 2 years, his blood pressures couldn't be managed with just amlodipine. Despite losing weight, BP was still higher than 160/100 mmHg. When he evaluated by his internal medicine physician, K level was significantly low (2.57 mEq/L). After oral potassium replacement and discontinuation of thiazide, it increased to only the lower limit (3.4 mEq/L). Abdominal CT showed bilateral adrenal thickness with 13 HU on the right and 10 HU on the left. On physical examination, he had no characteristic findings of hypercortisolemia or acromegaly. His BP was 180/100 mmHg, even he adopted salt-free diet and antihypertensive therapy with candesartan, thiazide, amlodipine. His echocardiography and retinal examination were normal. His catecholamine excretion on 24h urine was normal. After discontinuing aldosterone receptor blocker and thiazide, aldosterone and plasma renin activity were 73 ng/dL and 0.59 ng/mL/h respectively. The ratio was 123.7 and suspected highly of PA. The patient didn't want to be admitted to hospital for saline infusion test. He was directed to AVS. After medically controlling his BP, AVS was performed successfully in May 2022. His results are shown in Table-1. After this result, right adrenal gland was considered as PA source and right adrenalectomy was performed. The patient is on follow-up with single dose of candesartan within normal BP limits and normal K levels. CONCLUSION: COVID-19 pandemic has indisputably changed certain algorithms in every field. On this matter, patient specific approaches have become more important. Most specifically for this case, even when the hypertension started early-on-set, clinicians should seek the hypertensive end-organ injuries to understand the onset of the secondary reasons of hypertension. It should be remembered that not every early-on-set hypertension is secondary, and not every late-on-set hypertension is essential. [Figure: see text]