A RARE CASE OF PHEOCROMOCYTOMA IN PREGNANCY EXACERBATED BY METOCLOPRAMIDE

Abstract

Objective: Pheocromocytoma (PHEO) is a rare catecholamines secreting tumor presenting with variable clinical setting, mostly with headaches, sweating, palpitation and poor controlled arterial hypertension. In 85–90% of cases, tumors are of adrenal gland origin while in 10–15% are commonly located in paravertebral sympathetic plexus. The prevalence of PHEO in hypertensive patients ranges between 0.1 and 0.6%; PHEO is extremely rare during pregnancy with a prevalence of 1 in 54000 pregnancies thus, delayed diagnose may cause life-threatening situations. Accurate identification of PHEO during the antenatal period reduces the risk of mortality for mother and fetus. Design and method: We described a case of 33 years old pregnant woman with a one-year history of grade I hypertension. Results: The patient has been previously evaluated by endocrinologist for the onset of “striae rubrae” associated with illness, muscle pain, asthenia, anxiety, palpitations and weakness; lab tests were negative for hypercortisolism thus clinicians hypothesized a “functional syndrome”. However, during the 28th week of gestation she was admitted to the emergency room because of severe headache and severe arterial hypertension. CT brain scan was negative for acute events, lab tests showed mild hypokalemia and proteinuria. An in depth revaluation of the clinical history revealed a treatment with metoclopramide taken one week earlier. Conclusions: Metoclopramide can stimulate catecholamine- and granin-derived peptide secretion from PHEO cells through activation of serotonin type 4 (5-HT4) receptors and induced PHEO crisis. Thus, under suspicion of PHEO exacerbated by metoclopramide we performed lab tests resulted positive for catecholamines secretion while aldosterone and renin levels were normal. Abdomen ultrasound and MRI showed oval lesion located in right adrenal gland confirming diagnosis of PHEO. We started treatment with alpha and beta blockers associated with calcium-antagonist; at 33th week, patient underwent a caesarean section and after seven weeks a videolaparoscopic right adrenalectomy, obtaining a normalization of blood pressure levels.