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Correspondence to Dr Ebbe Eldrup; [email protected]
Background
Hypertension is a common disease, and for 90%–95% of the people suffering from this, an underlying causality cannot be identified.1 Many secondary reasons for hypertension do however exist, including primary hyperaldosteronism and adverse effects to different types of medication.2
Patients suffering from primary hyperaldosteronism have abnormally high levels of aldosterone, which induces hypertension and hypokalaemia through its binding to the mineralocorticoid receptor along with a suppression of plasma renin levels.3 Aldosterone and cortisol are both able to bind and activate the mineralocorticoid receptor in the kidneys, but cortisol’s activation is normally inhibited by the 11-β-hydroxysteroid dehydrogenase type 2 (11β-HSD2) enzyme, which converts cortisol into cortisone (see figure 1). Reduced activity of the 11β-HSD2 enzyme may cause cortisol activating the mineralocorticoid receptor. This causes a state of apparent mineralocorticoid excess,4 and results in patients presenting with clinical features resembling primary hyperaldosteronism.
We report two cases of itraconazole induced pseudohyperaldosteronism, an association that has only recently and very sparsely been reported.5–7 Due to the marital relationship between the two cases, the patients will be referred to as ‘wife’ and ‘husband’ in the following sections.
Case presentation
Wife
In the beginning of April 2020, a 66-year-old woman was admitted to the emergency department (ED) with hypokalaemia and hypertension. She had suffered from onychomycosis of her toenails (figure 2) for the past 10 years, but was otherwise known to be a healthy woman, including potassium (K+) levels within the normal range. She had no abnormal use of artificial sweeteners or liquorice that could imply syndrome of apparent mineralocorticoid excess. She had received treatment with oral terbinafine for the onychomycosis with no effect, followed by repeated 3 months treatment courses with oral itraconazole 200 mg/day, supplemented with continuous amorolfine nail varnish with some effect, though reoccurring after a few months. Trichophyton rubrum was cultured, confirmed by PCR. Fungus was found resistant to terbinafine, and less sensitive to itraconazole. She had been taking itraconazole 100 mg two times per day since September 2019.
During the week prior to admission, the patient suffered from headaches. Her general practitioner (GP) discovered that she had hypokalaemia and hypertension and admitted her to hospital. In the ED, blood pressure (BP) was...