Malignant Hypertension and Torsades De Pointes as Initial Presentations of Primary Aldosteronism

Primary aldosteronism (PA) is a common yet underdiagnosed cause of secondary hypertension, particularly in young patients presenting with severe disease.

A 31-year-old woman presented with malignant hypertension (264/144 mm Hg), severe hypokalemia (K⁺ level 2.60 mmol/L), and acute pulmonary edema. Her initial work-up during nicardipine and furosemide infusion showed a normal aldosterone-to-renin ratio (ARR), leading to misdiagnosis as essential hypertension. Over a 3-year follow-up, she developed refractory hypertension during pregnancy and preeclampsia. She was readmitted with torsades de pointes triggered by severe hypokalemia (K⁺ level 1.90 mmol/L). Repeat testing revealed a markedly elevated ARR (667.26). Adrenal venous sampling confirmed right-sided PA. Right adrenalectomy confirmed a cortical adenoma, with subsequent normalization of blood pressure and potassium levels.

This case report highlights the interference of common medications in PA diagnosis, delineates the complete pathophysiological cascade from aldosterone excess to life-threatening arrhythmia, and reveals the dynamic nature of PA-associated adrenal nodules.

Clinicians must be vigilant about the confounding effects of common antihypertensive agents on ARR interpretation and should consider adrenal imaging as part of the dynamic management of PA. Adrenal venous sampling remains paramount for surgical planning.