A case of pheochromocytoma which represented multiple myeloma like change
M. Sue1, D. Nagase1, F. Yamabe1, D. Sasai1, H. Willenberg2, S. Kamimura1, N. Hiroi1, K. Shibuya1 & G. Yoshino1
A 48-year-old female was admitted to our hospital because of prolonged fever of unknown origin for three months, anemia, renal dysfunction, and hypercalcemia. There were no abnormal parameters of physical examination except fever of 37.6 °C, BMI of 26 5 kg/m2 after 11 kg of body weight loss in 2 months, and her blood pressure was 138/87 mmHg. C-reactive protein and WBC were 24.6 mg/dl and 10 900/μl, respectively. A/G ratio was elevated with total protein of 8.7 g/dl and albumin of 1.6 g/dl, platelet count was 858×104, serum creatinine was 0.89 mg/dl. Plasma glucose and HbA1C level were elevated to 150 mg/dl and 7.4% respectively. As her bone marrow biopsy revealed hyper cellular bone marrow with an increased number of plasma cells, we diagnosed her multiple myeloma with Durie-Salmon stage III.
At the same time, abdominal CT scan revealed left adrenal mass with a diameter of 35 mm, which was strongly enhanced in enhance CT, and hyper-intense and heterogeneous on T2-weighted images in MRI. Urine adrenalin, urine noradrenalin, and urine dopamine were 14.5, 1470, and 3100 μg/day respectively. Addition with that, as I-131 MIBG adrenal scintigraphy demonstrated high uptake of left adrenal area, we diagnosed her pheochromocytoma.
To avoid the risk of inducing adrenal crisis by administrating steroid, we gave priority to the treatment for left adrenal pheochromocytoma and performed adrenalectomy. Serum and urine catecholamine levels were normalized after surgery. Anemia and hypercalcemia is also normalized, and the hyperglycemia which required 68 units of insulin per day before surgery had stabilized only with dietary cure. As the multiple myeloma like changes disappeared in bone marrow biopsy, we are following her carefully only with the oral medication for hypertension.
Though there are several reports of the IL6 producing pheochromocytoma with systemic inflammatory responses, we could not find any case representing the multiple myeloma like changes as we experienced. On the other hand, IL6 is the cytokine reported to be an autocrine growth factor in myeloma and plasmacytoma. There are possibilities that cytokine secretion from pheochromocytoma itself or from the necrotic lesion of pheochromocytoma led the plasma cells over expression and represented multiple myeloma like changes, which are all normalized after adrenalectomy for pheochromocytoma.
Declaration of interest: The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project.
Funding: This research did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.