Persistent hypertension post adrenal resection in a patient with surgically managed Connís Syndrome
A Moolla, P Behary, F Wernig, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London
We present the case of a 49-year-old man initially diagnosed with hypertension aged 29. Following a presentation with collapse and uncontrolled hypertension in 2012, he underwent biochemical investigations at his local endocrine centre and was diagnosed with Connís syndrome. Adrenal venous sampling confirmed hyperaldosteronism with lateralisation to the right adrenal gland, whilst computerised tomography imaging revealed a 16 mm adrenal adenoma. He subsequently underwent laparoscopic resection of the right adrenal gland in 2012. Whilst surgery was successful in treating his hypertension, he developed post-operative complications including pain and haematoma which resulted in further surgical procedures locally in 2013 following which he was discharged on no antihypertensive therapy.
Later in 2013, his hypertension recurred along with symptoms of headache and right flank pain. As these were to resistant to treatment, he was in 2016 referred to a tertiary surgical endocrine centre for further assessment. Magnetic resonance imaging revealed a lesion in his right adrenal bed and further revealed a left sided lesion that was felt to be a benign adrenal adenoma. Due to persistent pain and symptoms, he underwent surgical re-exploration of the previously operated site which resulted in the excision of a right sided mass adherent to the inferior vena cava. On histology, this was found to be a benign ĎSurgicel granulomaí, which was an inflammatory mass formed around absorbable surgical material used to control bleeding during his initial adrenal resection.
Between 2016 and 2019, he nevertheless remained hypertensive with a blood pressure in the community of around 180/130 mmHg and symptoms of ongoing right sided pain, nausea and headaches. On review in endocrine clinic in Aug 2019, his BP was 206/138 and potassium was low at 3.2 mmol/l despite being on 5 anti-hypertensive agents including eplerenone, lisinopril, indapamide, doxazosin and amlodipine. Between August and October 2019, these agents were adjusted in a stepwise fashion to a combination of verapamil, hydralazine and doxazosin to allow for assessment of plasma aldosterone and renin. On this regimen, his aldosterone:renin ratio was 112 (morning result) and 100 (afternoon result) (aldosterone 280 and 310 pmol/l; renin 2.5 and 3.1 nmol/L/hr). These results excluded a diagnosis of Connís recurrence. Other endocrine causes of hypertension were also ruled out and he is currently awaiting admission to assess for medication compliance and optimisation of anti-hypertensive therapy.