A 42 year old man was referred to the acute medical unit with accelerated hypertension in March 2015. He presented with headache and blurred vision due to hypertensive retinopathy. Pre-treatment BP was 186/131 mmHg. Initial treatment included amlodipine, bendroflumethiazide and losartan. Prior to discharge, a 24 hour urine collection showed a significantly elevated urinary noradrenaline level (3091 nmol/d, reference 0473). Referral was made to the cardiovascular risk clinic for further investigation. Unfortunately, due to several missed appointments he was not followed up until May 2015. It transpired that the patient had a long-standing history of depression and substance misuse. He had previously taken alcohol to excess but more recently had replaced this with amphetamines in the form of base, the potent base form from which amphetamine (speed) is manufactured. At review, 24 hour ambulatory BP measurement revealed severe, uncontrolled hypertension (mean daytime BP 164/104) with loss of the nocturnal dip. An ECG also showed LVH. A second 24 hour urine collection again showed elevated urinary noradrenaline (6445 nmol/d) and plasma normetanephrine was >25 000 pmol/l. The patient attended for an abdominal MRI scan in July 2015 which showed a large left adrenal lesion measuring 7.3 × 7.4 × 7.0 cm. Despite having the consequences of severe hypertension due to untreated phaeochromocytoma explained, this did little to encourage regular engagement or adherence to medication. In addition to substance misuse and the chaotic lifestyle ensuing, the patient also had anxiety issues around attending hospital. He eventually began to attend the endocrine service where he was offered weekly appointments most of which were not attended. He was often found to be symptomatic of postural hypotension when he did attend. Biochemistry showed the development of mild non-PTH dependent hypercalcaemia. He declined to attend hospital on two occasions for adrenalectomy. He was eventually persuaded to attend on the third occasion where he had a short admission under endocrinology for pre-operative management prior to transfer to the surgical unit where he underwent adrenalectomy in November 2016. Histopathology confirmed this to be a phaeochromocytoma with a PASS of 9. No genetic mutations were found. Since adrenalectomy the patient has been lost to follow-up. This case demonstrates the extraordinary challenges of managing a patient with a phaeochromocytoma who also abuses amphetamines and has other mental health problems. It remains to be seen if the patient will re-present with recurrent metastatic disease given his elevated PASS.
16 - 18 Apr 2018
Society for Endocrinology