A case dilemma: When the IVC aldosterone cortisol ratio is higher than the adrenal vein ratio in a case of primary hyperaldosteronism

Abstract

Primary aldosteronism (PA) is an underdiagnosed cause of resistant hypertension. The classic presentation is hypertension and hypokalemia. It is presented commonly as either bilateral or unilateral adrenal hyperplasia. The conformed test that has the ability to distinguish between them is Adrenal venous sampling (AVS) which has higher challenges in the right adrenal gland due to the anatomical course of the right adrenal vein that is supplied.Therefore, AVS is crucial in the subtype classification of PA, as relying on imaging alone can miss small APA (false negative) or identify coincidental nonfunctioning adenomas (false positive). In our patient, the successfully performed AVS test based on cortisol levels showed paradoxically low aldosterone-cortisol ratios bilaterally. This would raise the possibility of ectopic aldosterone-producing adenoma or super selective cannulation of the right adrenal vein which was the situation of our patient.