Hyperaldosteronism Clinical Presentation

Primary hyperaldosteronism may be asymptomatic, particularly in its early stages. When symptoms are present, they may be related to hypertension (if severe), hypokalemia, or both.

The spectrum of hypertension-related symptoms includes the following:

• Headaches
• Facial flushing
• If hypertension is severe, weakness, visual impairment, impaired consciousness, and seizures (hypertensive encephalopathy)

Hypokalemia can be precipitated by non–potassium-sparing diuretics or sodium loading. Symptoms of hypokalemia include the following:

• Constipation
• Polyuria and polydipsia (because of impaired renal concentrating ability)
• Weakness
• If the serum potassium is low enough, paralysis and disturbances of cardiac rhythm^[5]

Hyperglycemia or frank diabetes mellitus is possible because insulin secretion is a potassium-dependent process that may be impaired by hypokalemia.

If secondary hyperaldosteronism is suspected as the cause of hypertension, the history should include questions about flushing, diaphoresis, anxiety attacks, and headaches (pheochromocytoma) and about hematuria and abdominal fullness (Wilms tumor or other renal tumor), in addition to the above symptoms.^{[6, 7]}

For patients in whom secondary hyperaldosteronism is suggested, questions should be specifically directed at potential causes (eg, the presence and duration of swelling, the child’s exercise tolerance).

Information should be sought about a family history of essential hypertension and familial syndromes, including the following:

• Neurofibromatosis (associated with renal artery stenosis and pheochromocytoma)
• Multiple endocrine neoplasia (MEN) type 2 – This includes MEN 2A (parathyroid adenoma, medullary thyroid carcinoma [MTC], and pheochromocytoma) and MEN 2B (mucosal neuromas of eyelids, lips, and tongue with a long thin face, pheochromocytoma, and MTC)
• von Hippel-Lindau syndrome - Cerebellar hemangioblastoma; renal and pancreatic cysts and carcinoma; hemangiomas of the retina, liver, and adrenal glands; and pheochromocytomas

In any child or adolescent with significant hypertension, a thorough investigation into the cause is warranted. Hypermineralocorticoidism should be considered in any patient with associated hypokalemia, though it should not be excluded in the absence of hypokalemia. In patients with significant hypertension, blood pressure should be measured several times, preferably with an automated device after a supine rest.

Examination of the hypertensive patient should include the following:

• General examination – Be alert for dysmorphic features (eg, MEN 2B), evidence of neurofibromatosis type 1 (NF-1; ie, café-au-lait lesions, axillary freckling, short stature, and evidence of disease in parents), and features of Cushing syndrome (ie, obesity, short stature, striae, and hirsutism)
• Neck examination – Assess for a thyroid mass (MTC associated with MEN 2)
• Cardiovascular examination - Assess left ventricular muscle mass and exclusion of murmurs and pulse differential (eg, coarctation of the aorta); check for abdominal bruits (renal artery stenosis) and peripheral edema (secondary hyperaldosteronism)
• Abdominal examination – Look for masses (Wilms tumor), hepatomegaly (cardiac failure or liver disease), splenomegaly, and ascites
• Neurologic examination - Examine the eyes, and assess visual acuity (severe hypertension may interfere with vision); examine the eye grounds (looking for retinal angiomas [von Hippel-Lindau syndrome]); be alert for hypertensive retinopathy, which is of prognostic significance, including arterial narrowing, hemorrhages, cotton-wool spots, and papilledema; assess for Lisch nodules of the iris (NF-1)
• Strength assessment - Evaluation for weakness, focal neurologic signs, or impaired conscious state in a patient with severe hypertension, which requires urgent treatment and central nervous system (CNS) imaging to exclude infarction or hemorrhage
• Skin examination - In patients who have secondary hyperaldosteronism, look for evidence of NF-1

The main complications of primary hyperaldosteronism are hypertension and hypokalemia.

Hypertension due to hyperaldosteronism can damage many organs and organ systems, including the heart (hypertrophy and myocardial fibrosis), the blood vessels (vascular remodeling with medial and intimal hypertrophy and acceleration of atherogenesis), the eyes (arterial narrowing, retinal ischemia, and papilledema), the kidneys (progressive deterioration with nephrosclerosis), and the brain (hemorrhage). Aggressive blood pressure control and early diagnosis and treatment of the underlying hyperaldosteronism minimize the risk.

Hypokalemia initially results in weakness, constipation, and polyuria; when it is more severe, it may cause cardiac arrhythmias. Patients receiving cardiac drugs are at greater risk for this complication.