An 87-year-old man presented with a gastric ulcer; its pathology rev- ealed aseptate fungal hyphae consistent with mucormycosis. The patient's past medical history was remarkable for bilateral adrenal his- toplasmosis complicated by primary adrenal insufficiency which had been diagnosed one-year prior to this presentation; he has well responded well to voriconazole (VCZ) and prednisolone replacement. Intravenous lipophilic amphotericin B was given for a one-week dura- tion, and was then switched to oral daily posaconazole (PCZ) 300 mg. Two weeks later, the patient's blood pressure rose to 180-200/100-110 mmHg and hypokalemia with metabolic alkalosis (K + 2.2 mEq/L, bicarbonate 34 mEq/L) occurred. Posaconazole- induced pseudohyperaldosteronism (PIPH) was proposed due to his suppressed plasma renin activity (0.17 ng/mL/hr, reference 0.2-2.85) and low aldosterone levels (3.24 ng/dL, reference 4-31) while the PCZ levels were 3.99 μg/mL and 2.43 μg/mL, respectively (therapeu- tic levels for treatment >1 μg/mL). One week later, his hypertension and electrolyte abnormalities resolved with 100 mg of spironolactone daily. Subsequently, PCZ was switched back to VCZ after repeated gastroscopy showing an improving ulcer and no further bleeding.
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