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Abstract

Case Reports: Paragangliomas are rare neural crest tumors of sympathetic (generally catecholamine producing) or parasympathetic (rarely catecholamine producing) origin. The clinical picture is varied and diagnosis often difficult. Anaesthesia and surgery in unsuspected cases have high mortality. The clinical difficulties and challenges increase manifold in patients with undiagnosed or accidental diagnosis of pheochromocytoma who present to hospital for the treatment of some another disease. We report a similar case who presented with increased per vaginal bleeding. Case report A 49-year-old female, 55 kg, with presented to hospital with history of per vaginal bleeding since 15 days. She was non-hypertensive, non-diabetic & was not suffering from any other illness in the past. She had two living children with uneventful ante & postnatal course. Her menstrual history was normal. She was pale.Her blood pressure was 130/80 mmHg. Haemoglobin was 9.5 g/dl with normal coagulogram. Other routine blood and urine investigations, liver and thyroid function tests, electrocardiogram (ECG) and echocardiogram were normal. USG Abdomen showed about 57 mm × 34 mm × 38 mm diameter oval precaval solid echogenic mass with well-defined margins & smooth surface with 5 mm diameter tiny cystic spaces within, no calcification or sinus tracking. The mass did not show remarkable vascularity on Doppler located in duodenal “C” just caudal to the uncinate process of pancreas, compressing IVC away from aorta & right renal artery. There was no evidence of suprarenal mass. USG pelvis revealed large intramural fibroid. CT abdomen was done which showed enlarged heterogeneous necrotic mass mostly suggestive of precaval lymph node with compression of adjacent IVC. Multiple sub centimeter & centimeter sized necrotic lymph nodes in upper abdomen, gastro hepatic and celiac region. The possibility of lymphoma was strongly thought of. She was posted for excision of a suspected retroperitoneal mass after correction of anemia. GA was induced.Patient was haemodynamically stable during intubation and incision. The retroperitoneal mass 4cm × 4cm × 4cm was found over IVC below the renal vessel extending up to bifurcation of aorta free from duodenal or adrenal origin, suggestive of organ of zukerland. While dissecting the mass, there appeared sudden tachycardia, 150/ min and hypertension, 235/134 mmHg. This was followed by tachyarrhythmia initially and, later, idioventricular rhythms with varying, altered pulse beats. She developed cardiogenic pulmonary edema. These were managed effectively with diuretics & antihypertensive drugs. On excision of mass patient developed sudden hypotension which was managed with vasopressors. Development of severe arrhythmias, ST segment changes and hypertensive spikes during mass handling and dissection suggested the possibility of a catecholamine-secreting tumor. Subsequently, histopathology of the specimen revealed a paraganglioma.