Category: Adrenal Disorders

A SUBTLE PRESENTATION OF PHEOCHROMOCYTOMA: THE UTILITY OF AMBULATORY BLOOD PRESSURE MONITORING

Monday, Apr 8
1:00 AM – 2:00 AM

Objective :

We present a case of pheochromocytoma that initially presented with relatively asymptomatic hypertension. The patient was initially believed to have essential hypertension; however, ambulatory blood pressure monitoring and careful history taking raised suspicion for a secondary cause.


Methods :

We present the clinical, laboratory and imaging findings and a review of the literature. 


Results : A 60-year-old female with a one-year history of hypertension presented to the clinic for blood pressure management. She had not previously been prescribed anti-hypertensive medications. On presentation, her blood pressure was 154/87 and heart rate was 79 beats/minute. Twenty-four hour ambulatory blood pressure monitoring showed severe episodes of hypertension with tachycardia. Upon further questioning, the patient reported occasional headaches which correlated with the ambulatory hypertensive episodes prompting further workup. Twenty-four hour urine collection revealed normetanephrine level of 3352 ug/24 hours (normal 110-1050) and metanephrine level of 9219 ug/24 hours (normal 35-460). Renin, aldosterone, adrenocorticotropic hormone, and cortisol levels were normal. Computed tomography of the abdomen revealed a 4.6 x 5 centimeter right adrenal mass. She underwent right adrenalectomy with pathology revealing a 6 centimeter pheochromocytoma with no suspicious features. Plasma metanephrine and normetanephrine levels were normal post-operatively. Blood pressure normalized off anti-hypertensive medications.


Discussion : Pheochromocytomas are a rare secondary cause of hypertension and usually suggested by history, found incidentally on imaging, or related to familial disorders. The classic triad consists of episodic headache, sweating, and tachycardia; however, most cases do not present with all three signs or symptoms. Testing for a pheochromocytoma is recommended in patients with the classic triad, resistant hypertension, or familial syndromes. Paroxysmal hypertensive episodes on ambulatory blood pressure monitoring may further raise suspicion for a pheochromocytoma. Our case highlights the subtle presentation of a pheochromocytoma and the value of ambulatory blood pressure monitoring as well as careful history taking in order to determine which patients would benefit from screening.


Conclusion : Our case demonstrates that pheochromocytomas may have subtle presentations and although rare, are an important, reversible cause of hypertension. The absence of paroxysmal hypertension on ambulatory blood pressure monitoring does not necessarily exclude secondary causes of hypertension but the presence may support further investigation.

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Jessica Watari

Resident
Rutgers Robert Wood Johnson Medical School

Internal medicine resident

Joseph Ho

Resident
Rutgers Robert Wood Johnson Medical School

Internal medicine resident

Grace Bialy

Attending
Rutgers Robert Wood Johnson Medical School

Nephrology attending