Critical Care and Shock

An unusual presentation of pheochromocytoma

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Pheochromocytoma is a rare catecholamine-secreting tumor that may arise from chromaffin cells of the adrenal medulla, or extra-adrenal paraganglion tissue. Their prevalence in the general population is estimated at about 1 per 100,000 adults. Characteristically, patient presents with sustained or paroxysmal hypertension and the classic triad of symptoms which include episodic headache, sweating and tachycardia. There are numerous reports in the literature of unusual presentations of benign or metastatic pheochromocytomas including but not limited to multisystemic failure, hypertensive crisis, arrhythmias, catecholamine-induced myocarditis and cardiomyopathy, myocardial ischemia and infarction, pulmonary, cardiovascular, gastrointestinal, nephrologic and neurologic emergencies. This is the case of a 43-year-old male patient with previous medical history of hypertension. He went to a nearby clinic for evaluation of 6 day abdominal distention associated with nausea and vomits and pressure sensation on the epigastric area. Patient was admitted to an intensive care unit (ICU) with diagnosis of hypertensive crisis and upon arrival to the ICU an abdominal computed tomography (CT) scan was done where a 7.7 cm heterogeneous mass at the right adrenal gland was described, renal cell carcinoma was suspected. Patient was then transferred to our center. Upon arrival anti-hypertensive medication, nicardipine, was started. A new abdominal CT revealed a large right adrenal gland hemorrhage. Pheochromocytoma was considered among the working diagnosis. He was started on phenoxybenzamine and beta-blocker therapy. Urine/plasma metanephrines, catecholamines, creatinine and vanillylmandelic acid (VMA), were done. A magnetic resonance imaging (MRI) confirmed that the mass was of suprarenal origin. The diagnosis of pheochromocytoma was finally done. His hospital course was also remarkable for acute renal failure (ARF), supraventricular tachycardia, elevated liver transaminases and pancreatic enzymes, and mechanical intestinal obstruction. After acute clinical conditions resolved, patient tolerated diet and was discharged to continue outpatient therapy with phenoxybenzamine and metoprolol, to undergo surgery in the mainland United State of America (USA).

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