Abstract
Background:
Pheochromocytomas are neuroendocrine tumors that release large amounts of metanephrines and catecholamines, resulting in a wide array of symptoms including hypertension, diaphoresis, and headaches. If left unrecognized they can lead to serious morbidity including ischemic or hemorrhagic CVA, encephalopathy, MI, Aortic Dissection, and renal injury.
Clinical Case:
A 62-year-old male began having difficulties with his blood pressure over the past year. He was first hospitalized for an acute ischemic CVA with hypertensive urgency. His blood pressure was generally controlled throughout the admission but he continued to have intermittent elevations. After transferring to an inpatient rehabilitation unit he had an episode of acute nausea, severe lower abdominal pain, and emesis following dinner. He was tachycardic and hypertensive up to 190/115. Acute abdominal imaging revealed constipation but no obstruction. His symptoms resolved, returning a few hours later with another episode of acute nausea, vomiting, and severe lower abdominal pain, with blood pressure 210/126 and tachycardia. IV Metoprolol, Hydralazine and pain medications did not significantly improve his blood pressure, he was subsequently started on a Nitroglycerin drip. Abdominal workup was unremarkable, he was stabilized and discharged back to rehabilitation on increased oral medications. He continued to have blood pressure spikes up to 200/124 with nausea, vomiting, and severe abdominal pain until a Clonidine patch was started, after which his blood pressure was better controlled. He was discharged home with continued outpatient therapies.
A few weeks later he returned to the ER with nausea and severe abdominal pain, blood pressure at home was 254/185. On exam he was diaphoretic, tachycardic, and tachypneic. A CTA scan was obtained without signs of dissection. A Nitro drip with IV push Hydralazine were not effective at controlling his blood pressure, and so Lisinopril, Amlodipine, and a Clonidine patch were added. Over the next few days he had progressively fewer hypertensive elevations and his symptoms were only present during hypertensive episodes. An extensive workup for secondary hypertension was started. 24-hour plasma and urine Metanephrines were within normal limits. Urine Normetanephrine was elevated to 1266 ug/24h (Ref 88-444). Urine Norepinephrine was elevated to 124 ug/24h (Ref 15-80), Urine Dopamine was elevated to 578 ug/24h (Ref 65-400), and total Catecholamines were elevated to 133 ug/24h (Ref 15-100).
Conclusion:
This case illustrates the variance in presentations for Pheochromocytoma and the importance of maintaining a high index of suspicion for secondary causes in patients with intractable hypertension. While commonly reported symptoms include nausea and hypertension, the presentation of acute abdominal pain as the primary complaint is also an important feature of this disease.
Gastric Lipoma
