Category: Adrenal Disorders

PHEOCHROMOCYTOMA-THE CAUSE OF RENAL DEATH

Monday, Apr 8
1:00 AM – 2:00 AM

Objective :

Pheochromocytomas are rare chromaffin cell derived neuroendocrine tumors. Common presentation include paroxysmal episodes of headache, palpitation, sweating and hypertension. Life threatening complications including renal artery stenosis, and acute myocardial infarction had been reported from the possible mechanism of catecholamine-induced vasospasm and/or extrinsic compression of renal artery in some reported cases. Here, we report an interesting case of adrenal pheochromocytoma associated with renal infarction, unrelated to artery thrombosis/stenosis, and non- ST-elevation myocardial infarction.


Methods : n/a


Results : n/a


Discussion : A 48 year old male with no significant past medical history presents to the emergency room (ER) with sudden onset headache and blurring of vision. Vital signs revealed blood pressure of 215/120 mm of Hg. Examination showed no focal neurological deficits. Laboratory work including electrolytes was unremarkable. Imaging studies including CT head and CT angiogram of head and neck obtained revealed no evidence of intracranial hemorrhage. He left against medical advice at that time, but returned two days later to the ER with complaint of left flank pain. This time his vital signs showed blood pressure of 107/70 mm of Hg, and he had left sided abdominal tenderness. Laboratory work revealed troponin of 23.65 ng/mL [normal, <0.04ng/ml]. Abdominal and chest CT scan showed large wedge like non-enhancing region in the lateral mid to upper pole of left kidney and solid heterogeneous 4.9 cm right adrenal gland mass. Magnetic resonance imaging of abdomen showed heterogeneously enhancing right adrenal mass with patent main renal arteries. A pheochromocytoma was suspected, and doxazosin was added to his treatment regimen. He was also started on apixaban. Cardiac catheterization was deferred. 

Specific laboratory work revealed high levels of total plasma catecholamine, plasma metanephrine, nor metanephrine, and chrmogranin A respectively. Twenty-four hour total urinary metanephrines, normetanephrines, and catecholamines were also markedly raised. The patient underwent uncomplicated laparoscopic right adrenalectomy few weeks after this admission. Surgical pathology confirmed the diagnosis.


Conclusion :

Renal infarction from renal artery stenosis/thrombosis has been well documented in the literature. Our case is unique in its presentation, in that his renal infarct was independent of renal artery stenosis or thrombosis. We hypothesize, this was most likely from wide variation in blood pressure, and possible hypotensive episode, in the absence of obstructive coronary disease and renal artery stenosis. Clinicians should be aware of this clinical presentation for timely diagnosis.


 


 

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Sandiya Bindroo

Resident Internal Medicine
Crozer Chester Medical Center
Secane, Pennsylvania

Internal Medicine resident.

Malvika Duphare

Intern Internal Medicine
Crozer Chester Medical Center

Intern Internal Medicine

Lubna Zuberi

Chief, Endocrinology
Crozer Chester Medical Center

Chief, Endocrinology (Crozer, Springfield, Taylor)