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Catherine Alguire Division of Endocrinology, Department of Medicine and Research Center (CRCHUM), Centre hospitalier de l’Université de Montréal, Montreal, Québec, Canada

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Jessica Chbat Division of Endocrinology, Department of Medicine and Research Center (CRCHUM), Centre hospitalier de l’Université de Montréal, Montreal, Québec, Canada

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Isabelle Forest Department of Psychiatry, Centre hospitalier Pierre-Le Gardeur, Terrebonne, Québec, Canada

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Ariane Godbout Division of Endocrinology, Department of Medicine and Research Center (CRCHUM), Centre hospitalier de l’Université de Montréal, Montreal, Québec, Canada

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Isabelle Bourdeau Division of Endocrinology, Department of Medicine and Research Center (CRCHUM), Centre hospitalier de l’Université de Montréal, Montreal, Québec, Canada

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Summary

Pheochromocytoma is a rare tumor of the adrenal gland. It often presents with the classic triad of headache, palpitations and generalized sweating. Although not described as a typical symptom of pheochromocytoma, anxiety is the fourth most common symptom reported by patients suffering of pheochromocytoma. We report the case of a 64 year old man who had severe anxiety and panic disorder as presenting symptoms of pheochromocytoma. After 13 years of psychiatric follow-up, the patient was diagnosed with malignant pheochromocytoma. After surgical resection of his pheochromocytoma and his hepatic metastases, the major panic attacks completely disappeared, the anxiety symptoms improved significantly and the psychiatric medications were stopped except for a very low maintenance dose of venlafaxine. We found in our cohort of 160 patients with pheochromocytoma 2 others cases of apparently benign tumors with severe anxiety that resolved after pheochromocytoma resection. These cases highlight that pheochromocytoma should be included in the differential diagnosis of refractory anxiety disorder.

Learning points:

  • Anxiety and panic disorder may be the main presenting symptoms of pheochromocytoma.

  • The diagnosis of pheochromocytoma should be excluded in cases of long-term panic disorder refractory to medications since the anxiety may be secondary to a catecholamine-secreting tumor.

  • Surgical treatment of pheochromocytoma leads to significant improvement of anxiety disorders.

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Elise Flynn Austin Health, Heidelberg, Victoria, Australia

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Sara Baqar Austin Health, Heidelberg, Victoria, Australia
University of Melbourne, Parkville, Victoria, Australia

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Dorothy Liu University of Melbourne, Parkville, Victoria, Australia

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Elif I Ekinci Austin Health, Heidelberg, Victoria, Australia
University of Melbourne, Parkville, Victoria, Australia

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Stephen Farrell Austin Health, Heidelberg, Victoria, Australia

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Jeffrey D Zajac Austin Health, Heidelberg, Victoria, Australia
University of Melbourne, Parkville, Victoria, Australia

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Mario De Luise Austin Health, Heidelberg, Victoria, Australia

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Ego Seeman Austin Health, Heidelberg, Victoria, Australia
University of Melbourne, Parkville, Victoria, Australia

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Summary

ACTH-secreting phaeochromocytoma (ASP) is a rare cause of ACTH-dependent Cushing’s syndrome (CS). We report the case of a 63-year-old female presenting with CS secondary to an ASP complicated by bowel perforation. This case report highlights ASP as an uncommon but important cause of ectopic ACTH secretion (EAS). There have been 29 cases of ASP, all of which were unilateral and benign, but associated with significant complications. Patients presenting with ASP have the potential for cure with unilateral adrenalectomy. Given this promising prognosis if recognised, ASP should be considered in the diagnostic workup of ACTH-dependent CS. As this case demonstrates, gastrointestinal complications can arise from severe hypercortisolaemia associated with CS. Early medical and surgical intervention is imperative as mortality approaches 50% once bowel perforation occurs.

Learning points

  • Consider phaeochromocytoma in the diagnostic workup of ACTH-dependent CS; screen with plasma metanephrines or urinary catecholamines.

  • Serial screening may be required if ACTH-secreting phaeochromocytoma is suspected, as absolute levels can be misleading.

  • Early catecholamine receptor blockade and adrenal synthesis blockade may avoid the need for rescue bilateral adrenalectomy in ACTH-secreting phaeochromocytoma.

  • Consider early medical or surgical management when gastrointestinal features are present in patients with CS, as bowel perforation due to severe hypercortisolaemia can occur and is associated with significant mortality.

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