Abstract
Pheochromocytoma multisystem crisis (PMC) is a potentially lethal emergency due to catecholamine secretion. The condition manifests as severe hypertension to intractable cardiogenic shock and has a high mortality rate. This study explored the efficacy and safety of applying chlorpromazine on PMC patients. The study included seven patients (median age, 42 years; range, 14–57 years) diagnosed with pheochromocytoma. Four consecutive PMC patients were admitted to our critical care unit between 2016 and 2020 due to abdominal or waist pain, nausea, and vomiting. Their blood pressure (BP) fluctuated between 200–330/120–200 and 40–70/30–50 mmHg. Chlorpromazine (25 or 50 mg) was injected intramuscularly, followed by continuous intravenous infusion (2–8 mg/h). The patients' BP decreased to 100–150/60–100 mmHg within 1–3 h and stabilized within 3–5 days. Two weeks later, surgical tumor resection was successfully performed in all four patients. Similar clinical outcomes were also obtained in three patients with sporadic PMC reported in the literature who received chlorpromazine treatment, which reduced their BP readings from >200/100 mmHg to 120/70 mmHg. Our observations, combined with sporadic reports, showed that chlorpromazine efficiently controlled PMC. Thus, future studies on the use of chlorpromazine are warranted.
Highlights
Pheochromocytomas (PHEOs) and extra-adrenal paragangliomas (EAPs) are rare chromaffin cell tumors originating from adrenal chromaffin cells or extra-adrenal chromaffin cells in sympathetic and parasympathetic paraganglia, respectively [1]
Three of all four cases (Patient 1–3) we presented exhibited poor responses to phentolamine recommended in classic textbooks during Pheochromocytoma multisystem crisis (PMC) episodes, while chlorpromazine administration resulted in a dramatic control of oscillatory blood pressure (BP) during PMC episodes and remained stable with the frequency of hypertensive episodes in all four patients
Lee et al demonstrated that chlorpromazine inhibited catecholamine secretion in rat pheochromocytoma (PC12) cells by blocking nicotinic receptors and L-type voltage-sensitive calcium channels [28], while Donard et al reported that chlorpromazine inhibited glucose uptake and growth of PC12 cells [21, 29]
Summary
Pheochromocytomas (PHEOs) and extra-adrenal paragangliomas (EAPs) are rare chromaffin cell tumors originating from adrenal chromaffin cells or extra-adrenal chromaffin cells in sympathetic and parasympathetic paraganglia, respectively [1]. A 57-year-old woman presented with a right adrenal tumor and hypertension (systolic pressure occasionally reached 250 mmHg) 8 years previously without proper treatment, accompanied by burning pain in chest, with palpitations and pulsatile headaches in the supine position that had lasted for 1 year She began vomiting without apparent cause 2 days before her presentation. The patient showed poor response to phentolamine and esmolol, so chlorpromazine (25 mg i.m. and continuous i.v. infusion 3– 5 mg/h) and glucose saline were administered as described above Her symptoms were relieved after 1 h and BP gradually stabilized to around 120–100/70–50 mmHg within the 2 days (Figure 2C). She suffered from severe headache and body temperature reached 39.5◦C, suggesting signs of PMC Without using phentolamine, she was directly treated with chlorpromazine (25 mg i.m. followed by 3–4 mg/h continuous infusion, Figure 2D). The patient’s condition was stable and she was discharged 6 days after surgery
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