0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Special Feature |

Image of the Month—Quiz Case FREE

Brian K. P. Goh, MBBS, MRCS, MMed (Surgery); Yeh-Hong Tan, MBBS, FRCS; Jane Tran, MBBS, FRACP; Sidney K. H. Yip, MBBS, FRCS; Christopher W. S. Cheng, MBBS, FRCS
[+] Author Affiliations

Section Editor: Grace S. Rozycki, MD, MBA
Author Affiliations:Departments of Surgery (Dr Goh), Urology (Drs Tan, Yip, and Cheng), and Endocrinology (Dr Tran), Singapore General Hospital, Singapore.


Arch Surg. 2007;142(11):1103. doi:10.1001/archsurg.142.11.1103.
Text Size: A A A
Published online

A 56-year-old woman was referred with a history of poorly controlled hypertension of 5 years associated with hypokalemia, with potassium levels ranging from 2.1 to 3.0 mEq/L (the conversion from milliequivalents per liter to millimoles per liter is 1:1). Despite treatment with 2 mg of prazosin hydrochloride twice daily and 100 mg of atenolol every morning, her blood pressure remained elevated at 150/100 mm Hg. Her potassium levels could only be maintained at 3.5 mEq/L with 1200 mg of potassium replacement per day. Biochemical testing demonstrated a suppressed plasma renin activity of 150 pg/mL per hour (reference range, 660-3080 pg/mL per hour; to convert picograms per milliliter to picomoles per liter, multiply by 0.0237) and an elevated plasma aldosterone concentration of 33.2 ng/dL (reference range, 0.6-21.9 ng/dL; to convert nanograms per deciliter to picomoles per liter, multiply by 27.74). The elevated aldosterone to renin ratio of 221 supported a diagnosis of primary hyperaldosteronism (PH). A postural study after salt loading for 3 days was subsequently performed. This was inconclusive as the rise in the plasma aldosterone concentration was less than 30%. The biochemical results at 8 AMin the supine position were as follows: plasma aldosterone concentration, 30.0 ng/dL; plasma renin activity, 150 pg/mL per hour; and cortisol concentration, 11.5 μg/dL (to convert micrograms per deciliter to nanomoles per liter, multiply by 27.588). At 12 PMin the erect position, the results were as follows: plasma aldosterone concentration, 35.8 ng/dL; plasma renin activity, 70 pg/mL per hour; and cortisol concentration, 16.9 μg/dL. Computed tomography of the adrenal glands was performed (Figure) and the patient underwent adrenal venous sampling with corticotropin infusion, which demonstrated lateralization of aldosterone secretion to the left. The left-to-right cortisol-corrected aldosterone ratio was 13.5:1.

Place holder to copy figure label and caption
Figure.

Computed tomographic scan demonstrating a 9 × 8-mm well-defined nodule in the left adrenal gland suggestive of adrenal adenoma. This finding was atypical for adrenal hyperplasia, which usually appears as a diffuse enlargement of the gland.

Graphic Jump Location

WHAT IS THE DIAGNOSIS?

A. PH secondary to adrenal adenoma

B. PH secondary to bilateral adrenal hyperplasia

C. PH secondary to unilateral adrenal hyperplasia

D. PH secondary to adrenal carcinoma

Figures

Place holder to copy figure label and caption
Figure.

Computed tomographic scan demonstrating a 9 × 8-mm well-defined nodule in the left adrenal gland suggestive of adrenal adenoma. This finding was atypical for adrenal hyperplasia, which usually appears as a diffuse enlargement of the gland.

Graphic Jump Location

Tables

References

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Response

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections
PubMed Articles
JAMAevidence.com