Diagnosis and Treatment > Signs and Symptoms
University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
Search for other papers by Eka Melson in
Google Scholar
PubMed
Search for other papers by Sidra Amir in
Google Scholar
PubMed
University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
Search for other papers by Lisa Shepherd in
Google Scholar
PubMed
Search for other papers by Samina Kauser in
Google Scholar
PubMed
Search for other papers by Bethan Freestone in
Google Scholar
PubMed
Search for other papers by Punith Kempegowda in
Google Scholar
PubMed
Summary
Although pheochromocytoma classically presents with headaches, palpitations and paroxysmal hypertension, atypical presentations such as cardiomyopathy, stroke and subarachnoid haemorrhage have been infrequently documented. We present in this case report, an uncommon presentation of pheochromocytoma with myocardial infarction with normal coronary arteries (MINOCA). A 79-year-old woman presented with central crushing chest pain radiating to left arm associated with headache, palpitations, sweating and difficulty in breathing. For 2 years, she experienced brief episodes of headache, tinnitus, dizziness, palpitations, and sweating that spontaneously resolved. Clinical examination was unremarkable except for high blood pressure (210/105 mmHg). Her electrocardiogram showed T wave inversions from V1 to V6 and elevated troponins (774 ng/L at baseline and 932 ng/L 3 h from baseline (normal <16 ng/L) in keeping with a diagnosis of non-ST elevated myocardial infarction. Coronary angiography showed normal coronary arteries. Patient was hence treated as myocardial infarction with normal coronaries (MINOCA). Despite appropriate treatment for MINOCA, she continued to experience episodic headaches, palpitations, dizziness and erratic blood pressures (particularly severe hypertension shortly after beta-blocker administration). Further investigations revealed raised urine noradrenaline of 4724 nmol/24 h (<554 nmol/24 h) and urine adrenaline of 92863 nmol/24 h (<77 nmol/24 h). Computerised tomography demonstrated a well-defined rounded mass in right adrenal gland morphological of pheochromocytoma. She underwent laparoscopic right adrenalectomy with histology confirming pheochromocytoma. This case highlights the importance of thorough investigation for the underlying cause for MINOCA. In patients with unexplained erratic blood pressure control, pheochromocytoma should be considered as a differential diagnosis.
Learning points:
-
Pheochromocytoma is rare tumour that often presents with non-specific symptoms.
-
It is important to investigate underlying cause of MINOCA.
-
Thorough history is the key to diagnosis.
Search for other papers by Omayma Elshafie in
Google Scholar
PubMed
Search for other papers by Yahya Al Badaai in
Google Scholar
PubMed
Search for other papers by Khalifa Alwahaibi in
Google Scholar
PubMed
Search for other papers by Asim Qureshi in
Google Scholar
PubMed
Search for other papers by Samir Hussein in
Google Scholar
PubMed
Search for other papers by Faisal Al Azzri in
Google Scholar
PubMed
Search for other papers by Ali Almamari in
Google Scholar
PubMed
Search for other papers by Nicholas Woodhouse in
Google Scholar
PubMed
Summary
A 48-year-old hypertensive and diabetic patient presented with a 10-year history of progressive right facial pain, tinnitus, hearing loss, sweating, and palpitations. Investigations revealed a 5.6 cm vascular tumor at the carotid bifurcation. Her blood pressure (BP) was 170/110, on lisinopril 20 mg od and amlodipine 10 mg od and 100 U of insulin daily. A catecholamine-secreting carotid body paraganglioma (CSCBP) was suspected; the diagnosis was confirmed biochemically by determining plasma norepinephrine (NE) level, 89 000 pmol/l, and chromogranin A (CgA) level, 279 μg/l. Meta-iodobenzylguanidine and octreotide scanning confirmed a single tumor in the neck. A week after giving the patient a trial of octreotide 100 μg 8 h, the NE level dropped progressively from 50 000 to 25 000 pmol/l and CgA from 279 to 25 μg/l. Treatment was therefore continued with labetalol 200 mg twice daily (bid) and long-acting octreotide-LA initially using 40 mg/month and later increasing to 80 mg/month. On this dose and with a reduced labetalol intake of 100 mg bid, BP was maintained at 130/70 and her symptoms resolved completely. CgA levels returned to normal in the first week and these were maintained throughout the 3 month treatment period. During tumor resection, there were minimal BP fluctuations during the 10 h procedure. We conclude that short-term high-dose octreotide-LA might prove valuable in the preoperative management of catecholamine-secreting tumors. To the best of our knowledge, this is the first report on the successful use of octreotide in a CSCBP.
Learning points
-
The value of octreotide scanning in the localization of extra-adrenal pheochromocytoma.
-
Control of catecholamine secretion using high-dose octreotide.
-
This is a report of a rare cause of secondary diabetes and hypertension.
