Endocrine Abstracts

Pheochromocytomas are rare adrenomedullary tumours producing one or more catecholamines. Initial presentation in crisis due to catecholamine induced haemodynamic instability can mimic other more common causes of hypertensive emergency. We report a young person presenting with hypertensive crisis with a CT aortogram unveiling a pheochromocytoma. A 23-year-old trans female presented to the emergency department with sudden onset palpitations, clamminess and severe chest discomfort. She had a blood pressure of 224/140 mmHg, and a heart rate of 121 bpm. Electrocardiogram demonstrated right-bundle-branch-block with widespread T-wave inversions. Troponin I was elevated at 700ng/l. She was immediately transferred to the intensive care unit for management of hypertensive crisis. Blood pressure spontaneously dropped to 95/70 mmHg demonstrating marked haemodynamic instability. CT aortogram excluded aortic dissection but revealed right adrenal mass measuring 74x68x60mm with central cystic change and necrosis highly suggestive of phaeochromocytoma. She was initiated on cautious intravenous fluids along with alpha blockade with phenoxybenzamine due to unavailability of phentolamine. This was supplemented with intravenous magnesium sulphate providing both vasodilatory and alpha-blocking effect. Phenoxybenzamine 30mg twice daily maintained her blood pressure at target of below 130/80mmHg. Beta blockade in the form of bisoprolol was added once she was adequately alpha blocked. Subsequent results confirmed the diagnosis with elevated plasma normetadrenaline 3210 ng/l (0–200) with plasma metadrenaline 29.5 ng/l (0–100). As she had already been commenced on alpha-blockade, an MIBG scan could not be performed. Following multidisciplinary team discussion, an elective adrenalectomy is planned within 2-3 weeks. She is currently awaiting FDG- PET CT with plasma calcitonin and genetics test results pending. Pheochromocytoma can closely mimic acute cardiac events, particularly in young patients. In our case, the discovery of an adrenal mass during imaging for suspected aortic dissection helped to divert the management in the correct direction in a timely manner.