Asymptomatic Pheochromocytoma With Delayed Resection Due to Covid-19 and Persistent Postoperative Hypertension

Abstract

Background: Pheochromocytoma is promptly treated by surgical removal and usually results in resolution of hypertension. This case discusses an asymptomatic patient with two new malignancies-breast cancer and pheochromocytoma- who had positive outcomes despite delayed resection of pheochromocytoma due to COVID-19, but with a persistence of postoperative hypertension.Clinical Case: A 60 year old woman with newly diagnosed breast cancer presented for workup of an adrenal mass found on PET scan. An abdominal contrast CT-scan demonstrated a left 3.2 cm indeterminant adrenal mass. Initial laboratory testing demonstrated positive 24 hour urine metanephrines (metanephrine 951 mcg/24hr, n < 400 mcg/24hr for HTN and normetanephrine 1302 mcg/24hr, n < 900 mcg/24h for HTN) and plasma metanephrines (normetanephrine 826 pg/mL, n < 145 pg/mL and metanephrine 391 pg/mL, n < 62 pgmL), suggestive of pheochromocytoma. An MIBG scintigraphy showed tracer uptake in the left adrenal gland, suspicious for pheochromocytoma. The patient was started on alpha then beta blockade with plan for removal, but due to the COVID-19 pandemic, surgery was delayed. In the interim, breast cancer therapy was adjusted to avoid complications or symptoms from the possible pheochromocytoma. The patient had always been asymptomatic, even during the physical and emotional stress of cancer and chemotherapy. She only had a diagnosis of uncontrolled hypertension for four years prior to presentation, treated with Valsartan-Hydrochlorothiazide, with average systolic BP of 140–180, and diastolic BP of 80–100. With the addition of Doxazosin and Metoprolol, the patient’s BP improved, with all readings < 120/90. A left adrenalectomy was performed nearly six months after initial presentation, with final pathology report demonstrating moderately differentiated pheochromocytoma, with clean surgical margins. The patient remained hypertensive for months after the procedure, with initial systolic (SBP) readings of 150–160, and diastolic (DBP) readings of 90–100. However, follow up plasma metanephrine levels were normal (normetanephrine 165 pg/mL n < 191.8 pg/mL and metanephrine 22.1 pg/mL n < 88 pg/mL). The patient was then started on Amlodipine and Valsartan, with most recent SBP readings in the 130s.Conclusion: This case demonstrated a clinically asymptomatic patient with persistent postoperative hypertension and normal plasma metanephrines, which has been demonstrated only in a minority of patients. Additionally, pheochromocytoma needs to be promptly removed if possible; this case demonstrated successful resection and clinical course despite the delay for this urgent surgery due to COVID-19.