2. Case report
50M
Chief complaint: episodes of HTN and
palpitations
History:
-2006 HTN, crisis, max SBP 230mmHg,
headache, dizziness, excessive sweating… had
to admit to hospital
-2007 DM2
-Jan 2014 : gastric hemorrhage
3. Case report
Feb 2014: check-up at MEDIC-> suspected
tumor of the left adrenal gland Follow up
Still have the above symptoms ->cardiac
consult
Family history: his brother has mild
hypertension
11. Suspected pheochromocytoma the best plan
would be to do Metanephrin/plasma and 24h
Catecholamine/ urine
Surgery (BD hospital)
But… BD Endocrinologist/ Medic
13. Case report
Endocrinologist: hormonally inactive adrenal tumor
Follow- up
Come back cardiac consult for palpitations( a month
later):
Clinical context: HTN, DM2, episode of sweating,
palpitations and headache
Images: Left adrenal tumor
Laboratory test: normal metanephrin
Hormonally inactive adrenal tumor by Endocrinologist
Still suspected Pheochromocytoma
24h catecholamine/urine
20. Discussion
Pheochromocytoma is defined as chromaffin
cells derived catecholamine-producing tumor of
adrenal medulla.
Named by Ludwig Pick , pathologist, 1912
The first surgical removal of a
pheochromocytoma was performed by Cesar
Roux in 1926 in Europe and by Charles Mayo in
the USA in 1927.
A rare tumor with incidence of only 0.1% even
which is found incidently, occurs in 0.1-1% of
hypertensive patients.
23. Pheochromocytoma
The spells :
-from monthly to several times per day
-the duration may vary from seconds to
hours.
Paroxysms may be precipitated by
-physical training
-contrast media
-tricyclic antidepressive drugs
-metoclopramide and opiates
24. Pheochromocytoma: The Ten-Percent
Tumor
10% extra-adrenal (closer to 15%)
10% occur in children
10% familial
10% bilateral or multiple (more if familial)
10% recur (more if extra-adrenal)
10% malignant
10% discovered incidentally
1. MEN 2 syndromes (multiple endocronological
neoplasia)
2. VonHippel-Lindau‘s Diseases
3. Neurofibromatosis type 1
4. Familial Paraganglioma Syndrome
28. False negative plasma
metanephrine
<2 cm in size
DA-producing pheochromocytomas
->Recheck with a spell
->24-hour urine total metanephrines and
catecholamines
29. Pheochromocytoma and DM
Epinephrin > Norepinephrin in producing
hyperglycemia because of its higher affinity to the
β-2 adrenergic receptors.
In the pancreas : Epinephrine inhibits insulin
secretion mostly by stimulating α-2 adrenergic
receptor and probably by inducing glucagon
secretion via β adrenergic receptor
In the liver : Epinephrine increases transient
glycogenolysis and sustained gluconeogenesis by
stimulating β-2 adrenergic receptors
30. Pheochromocytoma and DM
DM in patients with pheochromocytoma :2–5%
Impaired glucose tolerance :12–75%
Very rarely, a patient with a pheochromocytoma
may present in diabetic ketoacidosis.
In young patients with HTN and normal body
weight, the presence of DM is a clinical clue to
the diagnosis of pheochromocytoma
J Clin Endocrinol Metab 2003;88(8):3632-36
J Hypertens 2003Sep; 21(9):1703-7
31. CONCLUSIONS
Rare opportunity to “kill two birds with one
stone”
Clinical context is always important
Skill of ultrasound doctor
Added 24-hour urine total metanephrines
and catecholamines /Medic test list.
