Abstract #1396724: Cryptic Catecholamines

Abstract

The textbook presentation of a pheochromocytoma is the pentad of severe headache, palpitations, significant perspiration, hypertension (HTN), and pallor. However, many patients present with subclinical findings, adding to the challenge for physicians to make this diagnosis. The following case is unusual in the patient’s history of three procedures under general anesthesia, with one being an ablation in 2019. A review of previous CT images showed an adrenal adenoma from 2019. This demonstrates that pheochromocytomas may have biochemically silent periods further complicating the diagnosis and management of pheochromocytoma. 78-year-old female presents s/p elective ablation with atrial tachycardia. PMH is remarkable for T2D, HTN, hypothyroidism, CAD, and atrial fibrillation/AVNRT. In 2019 patient had the first ablation without any complications related to blood pressure fluctuations. Due to unknown reasons, the patient had persistent atypical atrial fibrillation with dyspnea, with a plan to redo ablation for worsening symptoms of shortness of breath. Then in 2022 patient underwent a second ablation and developed labile blood pressure with initial findings of 77/48 with signs of cardiogenic shock and subsequent pulmonary edema. Due to the patient’s presentation of hypovolemia secondary to the development of cardiogenic shock, the patient required vasopressors. The patient was started on a beta-blockade in response to vasopressor treatment, which caused her blood pressure to increase significantly, with systolic pressures ranging between 230-240. The metoprolol was stopped, and the patient was transitioned to doxazosin, due to high suspicion of a pheochromocytoma. Initial stabilization of BP was achieved after starting an alpha blockade. BP remained somewhat labile but continued a downward trend with doxazosin. CT was later ordered and appreciable for a left adrenal mass. Past imaging records showed the mass had been present since 2019. Metanephrine labs were collected and found to be 6332 pg/ml, confirming the diagnosis of a pheochromocytoma. The patient was further stabilized with doxazosin and adequate volume resuscitation then transitioned to metoprolol with tight control of blood pressure. Her hospital course proved to be difficult due to prior comorbidities and age, but she was ultimately stabilized and discharged after a three-week hospital stay. A vast majority of patients with AFib have chronic HTN. There are many different etiologies of secondary HTN, including a more uncommon cause, pheochromocytomas. Common subclinical symptoms are as follows: headache, palpitations, sweating, HTN, and anxiety, which are also common presentations of AFib. Long-term management for pheochromocytomas would improve significantly if screenings were done in a patient presenting with symptomatic Afib and history of HTN. Positive screening would initiate early treatment, consisting of a short alpha blockade followed by a chronic, low-dose beta blockade. In this patient, the pheochromocytoma might have contributed to the failure of ablation treatments and the persistence of atrial fibrillation.