误诊多年的原发性醛固酮增多症1例

A Case of Primary Aldosteronism Misdiagnosed for Many Years

患者男,60岁,因情绪激动后出现胸闷、憋气半年余,伴有心慌、头晕、头痛收住我院心血管内科,既往高血压病史13年,规律服用“缬沙坦氨氯地平片”降压,血压控制不佳,最高为200/100 mmHg,“蛛网膜下腔出血颅内动脉瘤栓塞术后”10年,“右眼视网膜脱离”病史半年。否认吸烟饮酒史、心血管疾病及早发性高血压病家族史。入院检查心率65次/分,血压155/99 mmHg,一般情况及常规查体阴性,检验检查结果示血钾1.6 mmol/L,血钠147.8 mmol/L,尿液分析示PH 6.0,血浆醛固酮水平立位511 pg/mL、卧位655 pg/mL均升高,血浆肾素活性立位0 ng/mL/hr、卧位0 ng/mL/hr均降低,醛固酮/肾素活性比值(ARR)立位51.1、卧位65.5均升高,肾上腺CT动态增强扫描示双侧肾上腺见低密度结节影,考虑肾上腺皮质腺瘤所致的原发性醛固酮增多症,然后转泌尿外科行后腹腔镜下左肾上腺切除术,术后病理诊断为肾上腺皮质腺瘤,术后2周随访血浆醛固酮、血钾、血钠等生化指标水平均在正常范围,血压正常。

A 60-year-old male patient was admitted to the Department of Cardiovascular Medicine of our hos-pital because of chest tightness and suffocation for more than half a year after emotional agitation, accompanied by palpitation, dizziness and headache. He has a history of hypertension for 13 years and has been regularly taking “valsartan amlodipine tablets” for hypotensive for many years. His blood pressure has never been well controlled during the medication, with the highest value being 200/100 mmHg, with 10 years after intracranial aneurysm embolization for subarachnoid hemor-rhage, and half a year after retinal detachment in the right eye. The patient denied smoking and drinking history, family history of cardiovascular disease and early onset hypertension. On admis-sion, heart rate was 65 times/min, blood pressure was 155/99 mmHg, general condition and con-ventional physical examination were negative. The results of blood potassium and blood sodium were 1.6 mmol/L and 147.8 mmol/L, respectively. Urine analysis showed PH 6.0, and plasma al-dosterone levels increased in vertical position 511 pg/mL and recubitus position 655 pg/mL re-spectively. The plasma renin activity was decreased by 0 ng/mL/hr in vertical position and 0 ng/mL/hr in recubitus position, and the aldosterone/renin activity ratio (ARR) was increased by 51.1 in vertical position and 65.5 in recubitus position. Dynamic enhanced adrenal CT scan showed low- density nodular opacity in both adrenal glands, which was considered as primary aldosteron-ism caused by adrenal cortical adenoma. Then, the patient was transferred to the urology depart-ment for retroperitoneal laparoscopic left adrenal gland resection, which was pathologically diag-nosed as adrenal cortical adenoma. The plasma aldosterone, blood potassium, blood sodium and other biochemical indexes were all in the normal range and blood pressure was normal 2 weeks af-ter surgery.