New-Onset Resistant Hypertension in a Newly Diagnosed Prostate Cancer Patient

New onset resistant hypertension in a previously stable patient with chronic hypertension should lead to consideration of secondary causes. Electrolyte abnormalities are useful clues for identifying some common causes, especially mineralocorticoid excess.

We report the case of a 69-year-old man who developed severe resistant hypertension despite the use of 6 antihypertensive medications, including diuretics. He had metabolic alkalosis and hypokalemia with suppressed plasma renin activity and serum aldosterone. Concurrently, he was diagnosed with small cell neuroendocrine carcinoma of the prostate gland, a rare form of prostate cancer. Despite absence of typical Cushingoid features, investigation confirmed the diagnosis of ectopic adrenocorticotropic hormone (ACTH) syndrome from neuroendocrine prostate cancer. Because of the severity of his hypercortisolism, he underwent urgent bilateral adrenalectomy for hormonal and symptomatic control. Blood pressure improved significantly and he was dismissed with a single antihypertensive agent. Unfortunately, the patient died from his cancer 1 month later.

Primary and secondary hyperaldosteronism are usually diagnosed based on measurements of aldosterone and plasma renin activity. However, if plasma renin activity and aldosterone are both low, rare causes of mineralocorticoid excess such as ectopic ACTH syndrome should be entertained.