Refractory Hypokalemia in the Context of Bilateral Adrenal Hyperplasia Leading to Diagnostic Reassessment and Curative Surgery.

Primary hyperaldosteronism is a common cause of secondary hypertension and is often underdiagnosed. While bilateral adrenal hyperplasia is the most frequent form, the condition may evolve, and a unilateral aldosterone-producing adenoma can emerge, especially in cases presenting with worsening biochemical abnormalities. We report a case of a 60-year-old male patient with a history of bilateral adrenal hyperplasia who presented with life-threatening, asymptomatic hypokalemia (1.41 mmol/L), refractory to intravenous potassium supplementation. Electrocardiography revealed flattened T waves and prominent U waves. A contrast-enhanced CT scan showed a 22 × 19 mm right adrenal mass consistent with a benign cortical adenoma. Due to the urgency of the presentation, adrenal vein sampling was not performed. The patient underwent a laparoscopic right adrenalectomy, which resulted in rapid normalization of serum potassium and improved blood pressure control. Histopathological analysis confirmed an aldosterone-producing adrenal cortical adenoma with background nodular hyperplasia. This case highlights the potential progression of primary hyperaldosteronism, the importance of reassessing adrenal pathology in the presence of severe hypokalemia, and the effectiveness of surgical intervention in resolving both biochemical and hemodynamic disturbances.