The case: The case described is a 49 year old lady referred to emergency department with history of episodic palpitations, headache and sweating with possible weight loss for last 14 years but symptoms now worse in the past few days. Past medical history was significant for modest hypertension with retinal changes treated with Lisinopril. Patient stopped going to the gym recently as it seemed to exacerbate the symptoms. Patient recently registered with a new GP who in view of the above symptoms correctly organised 24-hour urine catecholamines and referred the patient to A&E. Systemic examination was unremarkable at time of admission with BP of 140/90, pulse rate of 72/min and RR of 14/min. However, patient seemed anxious. There was AV nipping and silver wiring on fundoscopy but no papilloedema or retinal haemorrhages. Rest of the systemic examination was unremarkable.
Results and management: The initial blood results were normal including sodium 139 mmol/l and potassium 4.3 mmol/l. Patient was referred to ambulatory care from A&E as clinically well. In view of strong suspicion of pheochromocytoma, patient was commenced on Phenoxybenzamine 10 mg twice daily and referred to urgent endocrine clinic. 24-hour urine catecholamine results showed grossly elevated urine noradrenaline 5427 nmol/24 h with normal urine adrenaline 78 nmol/24 h and urine dopamine 1468 nmol/24 h with a 24-hour urine volume of 3.7 l. The TFTs were unremarkable and ODST suppressed the cortisol to <30 nmol/l. Patient was booked for an urgent MRI adrenals which showed 35×32 mm mass arising from the right adrenal gland. The left adrenal gland appeared normal. Urgent referral was made to Kings College London and patient underwent a successful right laparoscopic adrenalectomy next month. Postoperatively blood pressure was 120/70 at next follow up and patient was not on any anti-hypertensive. She had a short Synacthen test post-operatively which showed adequate response of cortisol at 30 and 60 min and normal 24-hour urine catecholamine profile on few occasions since the surgery.
Discussion: The case describes a textbook presentation of pheochromocytoma. However, in our patient the symptoms although florid were present for many years before the diagnosis was made. Luckily for the patient it did not cause any significant morbidity or mortality. Also the case highlights the fact that pheochromocytoma is a rare but reversible cause of hypertension and patients can completely come off the antihypertensive medications after successful therapy as in the case of our patient.
16 - 18 Apr 2018
Society for Endocrinology