A diagnosis missed - until the third visit

43 year old man with past medical history of high blood pressure.

He had never had any surgeries and he drank alcohol only "socially," he had no siblings and his parents had "died very old." He worked as a truck driver until 4 months ago and hadn't really seen a doctor in over a year. Before that, because he traveled so much, he only saw doctors for sick visits...never for routine follow up. If you read between the lines there, he wasn't on any medications for his blood pressure.

Visit 1 to the hospital:

His white blood count was high, his blood pressure was high, his alcohol level was high and he was vomiting. We gave him intravenous fluids, multivitamins and a liquid diet. He slowly got better with this. Eventually, we stopped his iv fluids, advanced his diet and told him to drink less and sent him home. His blood pressure was high but never terribly bad.

The thinking was, alcohol or a viral illness caused the vomiting, which caused stress leading to higher than normal blood pressure.

He had told us that he had a high blood pressure history but wasn't taking meds for it. So, we started him on blood pressure meds; his blood pressure improved, his white blood cell count normalized and his symptoms disappeared - we discharged him. We made an appointment for him with a new primary care doctor as a follow up visit.

Visit 2 (around 2 months later):

Again, nausea and vomiting, again white blood cell count high, again high blood pressure but this time he had a low grade temperature and there was no alcohol in his system. He had "cheated" and eaten Mexican food before he got sick. He actually said that he had stopped drinking all together after his last visit. However, he never made it to that primary care doctors appointment.

So because of the temperature we thought he had gastroenteritis ie "stomach flu." Again he got iv fluids, got put on liquid diet and again he got better. We advanced his diet and he went home. We again told him to follow up with his new primary care doctor for his high blood pressure.

We had thought it was all bad luck...he ate some bad Mexican food and he got sick. Simple enough.

Visit 3 (1 months later):

Exact same visit as last time (nausea/vomiting and high blood pressure) except he had stopped drinking, he had stopped going out too much and he was keeping a low salt diet. Also, what was different this time was his white cell count was normal and he wasn't having fevers.

He had even made it to his primary doctor's office twice and had been taking his blood pressure medications. He did report that before coming in he had put some extra salt in his last few meals but kept repeating that he was really trying to "fix his life" and that it really wasn't "that much salt.". Also, this time his blood pressure really wasn't improving... it kept running high.

Now we were in a conundrum! If we were to believe him - this time around he got sick without any provocation. There was no alcohol, no viral illness, no bad food...something else was going on. Had his previous visits been the result of those things or was it the high blood pressure causing his symptoms and the rest of it was a red herring?

Which is the chicken... Which is the egg?

When you have high blood pressure - for the most part it's "essential hypertension." Meaning: you are obese, have a bad diet or you're old and your arteries are hardening and, you have high blood pressure. But, there's another possibility, something a bit harder to figure out: something else is raising your blood pressure - i.e. secondary hypertension.... the high blood pressure is the symptom not the disease.

For simple causes of secondary hypertension the list is fairly obvious: anger, anxiety, pain, emotional distress, physical stress.... All of these will raise your blood pressure. My patient didn't have any of these during this third visit.

Now we get into a whole host of other diseases that can cause high blood pressure.

Stroke, tumors that overproduce different hormones (cortisol, thyroid hormone, metanephrines, aldosterone to name a few), blocked kidney arteries, over use of Motrin type drugs (ie NSAIDs), cocaine use and sleep apnea are some examples.

Patient denied any drug use and we had a negative urine tox screen on him each of the visits. He denied any excessive Motrin or ibuprofen use as an outpatient. He definitely didn't have a stroke three times! He wasn't obese so sleep apnea became less likely.

We then ran extensive hormonal testing and ultimately he ended up having a cortisol secreting adrenal cancer.

Usually, adrenal tumors are found incidentally. Radiologist tend to call us and say: "hey your patient does have that colon infection you suspected but I also picked up nodules in his adrenal glands on the CT scan." My patient's tumor was so small that it had not been seen in the CT scans. It took an MRI to pick it up.

Moreover, women are three times more likely than men to get excessive cortisol production. Here was my first case ever and it was in a man!

He was referred to an endocrinologist on discharge. I haven't seen him in the hospital since then - I am guessing he underwent an adrenalectomy and was cured.