Coexistence of Primary Hyperaldosteronism and Graves’ Disease, a Rare Combination of Endocrine Disorders: Is It beyond a Coincidence—A Case Report and Review of the Literature

Abstract

Background Primary hyperaldosteronism is a known cause for secondary hypertension. In addition to its effect on blood pressure, aldosterone exhibits proinflammatory actions and plays a role in immunomodulation/development of autoimmunity. Recent researches also suggest significant thyroid dysfunction among patients with hyperaldosteronism, but exact causal relationship is not established. Autoimmune hyperthyroidism (Graves' disease) and primary hyperaldosteronism rarely coexist but underlying mechanisms associating the two are still unclear. Case Presentation A 32-year-old Sri Lankan female was evaluated for new onset hypertension in association with hypokalemia. She also had features of hyperthyroidism together with high TSH receptor antibodies suggestive of Graves' disease. On evaluation of persistent hypokalemia and hypertension, primary hyperaldosteronism due to right-sided adrenal adenoma was diagnosed. She was rendered euthyroid with antithyroid drugs followed by right-sided adrenalectomy. Antithyroid drugs were continued up to 12 months, after which the patient entered remission of Graves' disease. Conclusion Autoimmune hyperthyroidism and primary hyperaldosteronism rarely coexist and this case report adds to the limited number of cases documented in the literature. Underlying mechanism associating the two is still unclear but possibilities of autoimmune mechanisms and autoantibodies warrant further evaluation and research.

Hypokalemic paralysis in hyperthyroidism: Not all that glitter are gold

“…Several different causes of hypokalemia in the presence of hyperthyroidism have been increasingly reported. [9][10][11] Of note, the coexistence of Gitelman's syndrome and hyperthyroidism has been reported, mostly in young female of eastern Asian population. 11 In addition to diuretics, thyrotoxic patients may take laxatives for various purposes including weight reduction.…”

“…18,19 Mineralocorticoid excess states, such as primary aldosteronism and pheochromocytoma, presenting severe hypokalemia and hypertension have been reported in patients with hyperthyroidism. 10,20 With respect to therapy of severe hypokalemia, the dose of KCl (1 mmol/kg) should be minimized to prevent rebound hyperkalemia on recovery in TPP but a much higher dose of KCl is needed in the disorders of K + deficit. In general, there is a deficit approximately 750 mmol when plasma K + concentration close to 2.0 mmol/L.…”

“…Hypokalemic paralysis can be caused by renal tubular acidosis in patients with hyperthyroidism with or without concomitant Sjogren's syndrome 18,19 . Mineralocorticoid excess states, such as primary aldosteronism and pheochromocytoma, presenting severe hypokalemia and hypertension have been reported in patients with hyperthyroidism 10,20 …”

“…However, patients with hyperthyroidism may have chronic hypokalemia of divert causes such as use of diuretics, laxatives, or concurrent renal tubular disorders. [9][10][11] These nonthyroid causes of hypokalemia are often misdiagnosed as TTP with improper management especially when severe hypokalemia with paralysis is the primary presentation. In this report, we describe two young patients with hyperthyroidism-manifested profound hypokalemia and paralysis due to surreptitious use of loop diuretics and Gitelman's syndrome rather than TPP to illustrate the importance of the assessment of blood acid-base and spot urine electrolytes.…”

“…The presence of hyperthyroidism and severe hypokalemia is often said to be the signature of TPP. However, patients with hyperthyroidism may have chronic hypokalemia of divert causes such as use of diuretics, laxatives, or concurrent renal tubular disorders 9‐11 . These nonthyroid causes of hypokalemia are often misdiagnosed as TTP with improper management especially when severe hypokalemia with paralysis is the primary presentation.…”