Spectrum of mineralocorticoid hypertension.

Patient PresentationThe patient is a 70-year-old male who is actively employed as a loan adjuster.He was referred to the Clinical Study Center at San Francisco General Hospital because of persistent hypertension and reduced serum potassium concentrations.Three years before admission, he had sought medical attention because of decreasing stamina, tiredness, and a decrease in mental acuity during working hours.He was found to be hypertensive with blood pressures of 180/100 mm Hg and was started on diuretic agents.The diuretic and doses were changed a number of times, but hypokalemia was an almost constant feature unless supplemental potassium (80-100 meq/ day) was administered.A reduction of blood pressure was achieved.Eight months before his current admission, he was admitted to a hospital because of dizziness and fever.He had rhabdomyolysis, pneumonia, and a serum potassium concentration of 1.9 meq/1.All medications were stopped.He rapidly became hypertensive again; his blood pressure reached levels of 220/100 mm Hg and normalized only after that hospitalization with potassium supplementation and spironolactone, 100 mg/day.Without spironolactone or potassium supplementation, the serum potassium concentration ranged between 2.1 and 2.5 meq/1 with a serum sodium concentration of 138 meq/1.His hypertension management eventually included 240 mg verapamil (slow release).Blood pressure was maintained at levels below 140/100 mm Hg with therapy.Shortly after this, a search for correctable causes of his hypertension was initiated.Potassium supplements and spironolactone were discontinued for 3 weeks, and his blood pressure rose to 220/120 mm Hg.His serum potassium concentration gradually fell from 4.4 to 2.3 meq/1.A 24-hour urine sample for 17-hydroxy steroids and ketogenic