Cinical Chemistry

3
CASE STUDY

Mendoza, Princess Fatima Angela D.

Case Study # 1
 A 34-year-old woman has new-onset hypertension. Her
serum potassium level is 2.7 mmol/L. Initial
hormone screening shows a:
 plasma aldosterone (PA) of 55 ng/dL (normal [nl], 1–16)
plasma renin (PR) of 0.1 ng/mL/hour (nl, 0.15–2.33).
What is the probable diagnosis?
 Case Study # 2
 A 47-year-old female who was in good health. In her past Medical & Laboratory history, a fine-needle aspiration

biopsy of a dominant thyroid nodule in a multinodular goiter was performed and revealed papillary thyroid
cancer. The patient underwent a total thyroidectomy complicated by transient postoperative hypocalcemia. The
patient was withdrawn from thyroid hormone replacement therapy 6 weeks prior to referral for radioactive
iodine remnant ablation therapy. The patient was perimenopausal and last had menses a year ago although she
had a recent episode of vaginal bleeding. The patient denied sexual intercourse over the previous 5 years.
Based on the initial result, a urine hCG and repeat quantitative hCG was ordered 72 hours later to determine if
the levels were changing (Table 1). The attending endocrinologists contacted the laboratory to determine if the
hCG results were correct or whether there was some interference with the test result. The clinical laboratory
conducted an investigation as to the potential cause of this mildly increased and unchanging value.
Case Study #1
Answer
The presence of hypertension and hypokalemia suggests primary aldosteronism (Conn syndrome). The PA level is
elevated, the PR is suppressed, and the PA/PR ratio is greater than 20, supporting this diagnosis. The diagnosis
can be confirmed by demonstrating the failure of PA to suppress after volume expansion with intravenous saline
or oral salt loading. The next step is to establish whether the cause is an aldosterone-producing adenoma or
bilateral adrenal hyperplasia. Abdominal computed tomography (CT) should be performed. Because of her young
age and very low serum potassium level, an aldosterone-producing adrenal adenoma is the most likely cause. The
treatment for an aldosterone-producing adrenal adenoma is surgery. Spironolactone should be given to control
blood pressure and to normalize the serum potassium preoperatively
Case Study #2
Answer
1. Was the patient pregnant? -The principal question in this case was the interpretation of the hCG results.
Despite a positive quantitative serum and qualitative urine hCG result, a normal, viable pregnancy was ruled out
on the basis of the patient’s reported history and the unchanging values over time. In a normal pregnancy, the
hCG concentration typically doubles over 48 hours, which was not observed in this case. Abnormal pregnancies
such as ectopic and molar can have hCG concentrations that increase over time, although not to the extent seen
in normal pregnancy.
 2. Is this a false-positive result for hCG? -Having ruled out a viable pregnancy, it was necessary to determine the
etiology of the presumed false-positive increase in hCG. The medical team questioned whether or not the patient’s
high TSH might have produced a false-positive result for hCG as the alpha subunit is identical for hCG and TSH.
A similar concern could also be raised for follicle-stimulating hormone (FSH) or lutenizing hormone (LH) as they
also have the same alpha subunit. In studies conducted by the manufacturer, TSH, FSH, and LH concentrations
of 560 IU/L produced no apparent increase in hCG values. In addition, no interference was observed with high
concentrations of prolactin and human growth hormone.