Delayed diagnosis of primary hyperaldosteronismBMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c2461 (Published 25 May 2010) Cite this as: BMJ 2010;340:c2461
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Grasko et al (1) published a very interesting article in the June
issue regarding the diagnosis of primary hyperaldosteronism in the context
of management of hypertension. We would like to highlight another
important cause of delayed diagnosis of this condition, which may
masquerade as a neurological deficit.
We saw two cases of motor weakness of 48-72
hours duration without any localization. In both cases there had been similar episodes in the
past and primary hypokalemic periodic paralysis had been diagnosed, based
on low serum potassium levels. Weakness recovered fully following potassium replacement but persistent hypertension developed, with elevated plasma aldosterone levels,
reduced plasma renin activity, and an adrenal mass. Laparoscopic adrenalectomy led to resolution of
symptoms and normalization of blood pressure and serum potassium levels during follow up of six months to four years.
Although commonly presenting with a combination of hypokalemia and
hypertension, primary hyperaldosteronism can manifest in several ways, one
of them being motor muscular weakness.(2) Hypokalemic muscular weakness by
itself, is an uncommon presentation of primary hyperaldosteronism.
Adrenal adenoma (Conn's syndrome) and bilateral adrenal hyperplasia are
the most common causes of this condition.(3)
One should remember that hypertension and hypokalemia may not present
simultaneously in hyperaldosteronism. Hypertension may develop or
manifest at a later date. Therefore, all patients with so called
hypokalemic periodic paralysis should be diligently screened for
hypertension including an ultrasound of the adrenals. Unless there is a
high index of suspicion, these patients are often mistakenly diagnosed as
primary hypokalemic periodic paralysis. Therefore the evaluation of motor
weakness should include an intensive search for primary
hyperaldosteronism, which is potentially treatable by adrenalectomy in
patients with an adenoma.
1.Grasko JM, Nguyen HH, Glendenning P. Delayed diagnosis of primary
hyperaldosteronism. BMJ 2010; 340: c2461.
2.Kotsaftis P, Savopoulos C, Agapakis D, Ntaios G, Tzioufa V,
Papadopoulos V, Fahantidis E, Hatzitolios A. Hypokalemia induced myopathy
as first manifestation of primary hyperaldosteronism - an elderly patient
with unilateral adrenal hyperplasia: a case report. Cases J 2009; 2: 6813.
3.Conn JW, Knopf RF, Nesbit RM. Clinical characteristics of primary
aldosteronism from analysis of 145 cases. Am J of Surgery 1964; 107: 159-
Competing interests: No competing interests