Clinical Case of the Month: PERSISTENT HYPERTENSION IN A YOUNG WOMAN: A CLASSIC PRESENTATION OF CONN'S SYNDROME.

Primary aldosteronism PA is a secondary cause of hypertension that is often missed due to inadequate clinical evaluation and the lack of classically described laboratory abnormalities. Based on guidelines from the Endocrine Society, primary aldosteronism should be suspected in young patients with moderate to severe hypertension, patients with hypertension and coexisting hypokalemia, any patient with hypertension and an incidental adrenal adenoma, and hypertension in the setting of a significant family history of early onset hypertension or cerebral vascular accident in a first degree relative less than 40 years of age.1 In previous years, primary aldosteronism was attributed to less than one percent of all causes of secondary hypertension. However, recent research and increased utilization of aldosterone plasma renin ratio ARR as a method for screening has led to the understanding that majority of patients with PA are not hypokalemic, and the current literature now places the incidence of PA between 5-13 percent. Additionally, a growing body of evidence has demonstrated inflammatory, fibrotic, and remodeling effects on the cardiovascular and renal tissue that appear to be independent of PA- induced hypertension. Therefore a high suspicion for PA must be incorporated into evaluation of hypertensive patients, as diagnosis and subsequent treatment not only improves blood pressure control, but also acts to diminish cardiovascular morbidity and mortality. Here we present a case of a young woman with a seven-year history of hypertension prior to receiving a diagnosis of Conn's Syndrome.

Invasive Pneumococcal Disease and COVID-19 With Acute Otitis Media and a Tegmen Tympani Defect.

Streptococcus pneumoniae is a leading cause of otitis media, pneumonia, sinusitis, and meningitis. This encapsulated, gram-positive bacterium colonizes the nasopharynx. Major risk factors, including age, hyposplenism, and immunosuppression, predispose to serious infections. Viral infections are known to increase the risk of secondary bacterial infections as the initial immune response can compromise defenses against bacteria. Coronavirus disease 2019 (COVID-19) similarly poses a risk for secondary bacterial infections and coinfections, such as invasive pneumococcal disease (IPD). Still, temporal relationships between IPD and COVID-19 are not fully understood. IPD may also be a complication of untreated acute otitis media. COVID-19 and pneumococcal bacteremia, a form of IPD, have both been shown to damage the blood-brain barrier and gain access to the central nervous system, resulting in deep infections, namely, meningitis and encephalitis. Presented here is the case of a 70-year-old female partially vaccinated against pneumococcal disease, who was initially evaluated for an elevated temperature, acute encephalopathy, and COVID-19. Further investigation confirmed IPD in the form of bacteremia and meningitis. The patient had a protracted disease course complicated by sick sinus syndrome and altered mental status, which led to the identification of otitis media and a right tegmen tympani defect. Emergent implantation of a single-chamber temporary pacemaker and myringotomy with tube placement was performed. Lumbar puncture showed evidence of meningitis. Antibiotic therapy eventually narrowed to ceftriaxone and continued for a total of six weeks. The presence of comorbidities, history of incomplete pneumococcal vaccination series, and concomitant infection with COVID-19 may explain the development of IPD and other complications seen in this case. Furthermore, tegmen tympani defects and damage to the blood-brain barrier can serve as a route for otogenic intracranial sepsis and meningitis. This case serves to reinforce the importance of pneumococcal vaccination and the high clinical suspicion necessary for the prompt diagnosis and treatment of IPD. However, despite vaccination, IPD remains a life-threatening disease due to poor antibiotic penetration in the central nervous system and overlapping presentations with coinfections, such as COVID-19.