Резюме
Шупер В.А., Шупер С.В., Вагина Ю.И., Сигова А.В. Дифференциальная диагностика вторичной артериальной гипертензии.
В работе описан клинический случай первичного гиперальдостеронизма как причины вторичной эндокринной артериальной гипертензии и даны рекомендации по диагностике и дифференциальной диагностике больных с артериальными гипертензиями.
Ключевые слова: вторичные эндокринные артериальные гипертензии первичный гиперальдостеронизм, диагностика, скрининг.
Резюме
Шупер В.О., Шупер С.В., Вагіна Ю.И., Сігова А.В. Диференційна діагностика вторинної артеріальної гіпертензії.
В роботі описано клінічний випадок первинного гіперальдостеронізму як причини вторинної ендокринної артеріальної гіпертензії та дані рекомендації щодо діагностики та диференційної діагностики хворих із артеріальними гіпертензіями.
Ключові слова: вторинні ендокринні артеріальні гіпертензії, первинний гіперальдостеронізм, діагностика, скринінг.
Summary
Shuper V.A., Shuper S.V., Vagina Ju. I., Sigova A.V. Differential diagnoses of the secondary arterial hypertension.
In work the clinical case of Primary Aldosteronism as a reason of secondary endocrine arterial hypertension is presented; and measures of the diagnoses and differential diagnoses of the patients with arterial hypertension are recommended.   
Key words: secondary endocrine arterial hypertension, Primary Aldosteronism, diagnostics, screening.

Рецензент: д.мед.н., проф. Л.М. Іванова

УДК 616.12-008.31.1-08

ГЗ «Луганский государственный медицинский университет»

State Establishment "Lugansk State Medical University"

Луганская городская многопрофильная больница № 1

Lugansk City Hospital № 1

shooper@inbox.ru, sergej-shuper@yandex.ua

The frequency of secondary forms of arterial hypertension ranges from 5 % to 25 % of the total number of cases. Secondary arterial hypertension in most cases is characterized by severe course; it is refractory to therapy and needs special approach to treatment. List of causes of secondary arterial hypertension consists of more than 40 diseases or conditions.

Secondary endocrine arterial hypertension is characterized by increased blood pressure associated with different primary pathology of the endocrine organs. The most common causes of secondary arterial hypertension are thyroid diseases, Diabetes Mellitus, Cushing’s disease and syndrome. In addition, arterial hypertension is a major clinical manifestation of the pathology of the adrenal glands caused by aldosteron-producting tumors. It may be the reason in 9-15 % of all cases of arterial hypertension.

Primary hyperaldosteronism (PHA) (Cohn’s syndrome) is relatively rare endocrine disorder. It is not always diagnosed on time, thus causes difficulties in the correction of hypertension in these patients. Hyperaldosteronism prevalence up to 25% of patients with hypertension, and hypokalemia ("classic" PHA) is present in only 41% of patients. PHA usually occurs between the ages of 30-40 years, female to male ratio is 3:1. Rare identifying of PGA among patients with severe arterial hypertension indicates not only about the casuistry of the disease, but the lack of proper diagnosis. Difficulties in identifying of PHA and frequency of secondary arterial hypertension in therapeutic practice with needing of differential diagnosis were the basis for the description of the Cohn’s syndrome in a patient who was under our supervision in the therapeutic department.

Patient E., 50 years old, was admitted to the therapeutic department with complaints of dizziness, headache, general weakness, shortness of breath on slight exertions, periodic short stabbing pains in the heart area, cramping and swelling of lower extremities, nocturia, thirst and dry mouth. From anamnesis it was revealed that the patient suffers from hypertension for 10 years, hypertensive crises occur 1-2 times a month. She constantly takes antihypertensive therapy without stable effect and undergoes regular hospital treatment courses.

Data of objective examination: patient has moderate feeding; skin and visible mucous membrane have normal color with low humidity. Tone and powerful of muscles are reduced. Auscultatively vesicular respiration was heard, respiratory rate - 20 per min. Heart border was dilated to the left for 2 cm, and apical impulse was decreased. The heart rate was 80 beats per min., heart sounds were muffled, with rhythmic activity. BP 180/100 mm Hg. Abdomen was soft, painless on palpation in all departments. Liver protruded for 1 cm beyond the costal arc.
Daily diureses was of 3.5 liters with nocturia.

Results of additional investigation methods -
Complete blood count: hemoglobin - 104 g/l , erythrocytes - 3.7×10¹²/l , the CI - 0.85, leukocytes - 9.0×10⁹/l, ESR - 25 mm/h. Blood sugar: 3.86 mmol/l.

Coagulation test: PTI - 75%, plasma recalcification time - 69'', fibrinogen - 5.1 g/l, fibrinogen B – positive, trombotest - IV degree. Kidney function test: blood urea - 2.06 mmol/L, serum creatinine - 88.7 mmol /l, uric acid in the urine - 4.11 mmol/day. Blood electrolytes - potassium - 2.87 mmol/l, sodium - 146.5 mmol/l calcium in the blood - 2.64 mmol/l, calcium in the urine - 8.43 mmol/day. Phosphates in urine – 26.1 mmol/day.

Hormonal studies:  aldosterone - 331.38 pg/ml, renin - 4.78 ng/l, 17-CS - 85.04 mmol/day, 11 - ACS - 0.59 mmol/d, adrenaline - 18.25 nmol/day. noradrenaline - 120 nmol/day, dopamine - 735 nmol/day.

Urine: the relative density - 1010, response - slightly alkaline , protein - neg., sugar - neg., leucocytes - 1-2 in f\v, mucus – small, salts - phosphates.

ECG: left ventricular hypertrophy, expressed diffuse myocardial changes, ECG signs of hypokalemia (decreased voltage of the T wave, the expansion of  Q-T interval).

Ultrasound of kidneys and adrenal glands: Kidneys are symmetrical, regular shape, structure and position. The cups are deformed and underlined, left kidney contains two calculus (5 and 4 mm in diameter). Urodynamics is not broken. The right adrenal gland size – 22x15 mm, left – 19x18 mm. Computed tomography of the abdomen: In the projection of the lateral legs of the left adrenal gland mass is determined with oval form, clear smooth contours and size 18,5x16,5x10,0 mm with low density. Conclusion: CT-picture of aldosteroma.

On the basis of complaints, anamnesis, physical examination data and the results of additional research methods three characteristic syndromes were identified - hypertension, neuromuscular syndrome, polyuria - polydipsia. Clinical diagnosis was made – Aldosteroma of the left adrenal gland. Primary hyperaldosteronism. Secondary endocrine arterial hypertension. As antihypertensive pathogenic therapy verospiron (100 mg) was prescribed for the patient (1 tab. 3 times a day), the effect of treatment was satisfactory. The patient was directed to the Institute of Endocrinology in Kiev to decide on surgical treatment.

In conclusion, it should be noted the need for directional screening of endocrinopathies as causes of hypertension for the timely and effective etiopathogenetic adequate treatment. Diagnostic study must include a minimum of potassium and sodium levels in blood, calcium level in blood and urine, thyroid stimulating hormone, blood creatinine level. If necessary, the survey plan can be augmented by research of cortisol, aldosterone, adrenaline, renin, thyroid hormones, and instrumental methods of topical diagnosis of endocrinopathies.

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