Unmasking Secondary Hypertension: Renal Artery Stenosis Concealing the Diagnosis of Primary Hyperaldosteronism

Unmasking Secondary Hypertension: Renal Artery Stenosis Concealing Primary Hyperaldosteronism

A 24-year-old woman without previous health issues presented with severe, treatment-resistant hypertension. She experienced episodic headaches and maintained systolic blood pressures above 140 mm Hg despite lifestyle changes.

Initial Evaluation

Laboratory tests showed hypokalemia and metabolic alkalosis. The aldosterone-to-renin ratio suggested primary hyperaldosteronism, but was not diagnostic. Further tests ruled out pheochromocytoma, Cushing's syndrome, and thyroid disorders.

Imaging and Findings

Imaging revealed right renal artery fibromuscular dysplasia with about 30% narrowing on angiography. Despite maximum medical therapy, hypertension persisted, and later imaging showed stenosis progressed to 70-75%, leading to angioplasty.

Intervention and Outcomes

Angioplasty improved artery patency but did not normalize blood pressure or correct hypokalemia. Subsequent evaluation found a 1.7 cm mass on the left adrenal gland. Adrenal venous sampling confirmed unilateral aldosterone overproduction.

Definitive Treatment

The patient underwent laparoscopic adrenalectomy. Pathology confirmed an aldosterone-producing adenoma. After surgery, potassium levels normalized and blood pressure remained stable without antihypertensive drugs.

This case highlights the diagnostic challenges when two secondary causes of hypertension coexist. Fibromuscular dysplasia initially diverted attention from primary hyperaldosteronism, delaying definitive diagnosis and curative treatment.

Author's summary: Coexisting renal artery stenosis and primary hyperaldosteronism can obscure diagnosis, requiring thorough re-evaluation to ensure timely and effective treatment.

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Cureus Cureus — 2025-11-06

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