LBODP015 A Pheochromocytoma Presenting With Hypertensive Emergency With A Rare Complication Of Unilateral Adrenal Hemorrhage

Abstract

Abstract Introduction Adrenal hemorrhage is an uncommon finding in patients and is estimated to be present in 0.14-1.8% of postmortem examinations. Clinical diagnosis is challenging due to its non-specific presentation and most cases are diagnosed incidentally on imaging. Here we discuss the clinical presentation, diagnostic procedures, and outcome of this rare case. Clinical Case A 74-year-old Asian female presented to the ED with a sudden onset of severe epigastric pain with 9/10 intensity, radiating to her upper back while walking on the street. She was found in severe distress with a blood pressure of 214/80 mmHg, heart rate of 72 bpm, respiratory rate of 20 breaths/min, and oxygen saturation of 98% on room air. The physical exam was unremarkable. Laboratory findings were significant for elevated troponin of 1. 040 ng/ml (0. 00-0. 03 ng/ml), lactate 2.36mmol/L (0.70-2. 00 mmol/L), and lipase 481U/L (23-300 U/L). Chest X-ray was within normal limits. A CT angiogram of the chest and abdomen were negative for aortic dissection, however, a retroperitoneal hemorrhage measuring 6×8.5×6.5 cm was seen but an underlying adrenal gland mass could not be excluded. The patient was started on nitroglycerine drip for blood pressure control. Hemoglobin trend showed an acute drop, requiring 2 units of red blood cell transfusion. This raised concerns of worsening hemorrhage. Repeat imaging showed no significant change in the left adrenal hematoma, but arterial phase imaging still suggested active bleeding. Interventional radiology was consulted, and embolization of the left superior and inferior renal artery was done with stabilization of the patients hemodynamics. Laboratory work for secondary causes of hypertension was done. It showed elevated normetanephrines 1281 mcg/24hr (122 - 676 mcg/24hr) and total 24-hour urine metanephrines, 114 mcg/24hr (224-832 mcg/24 hr). The patients blood pressure was controlled and therefore asked for follow-up as an outpatient. Conclusion The majority of adrenal hemorrhages diagnosed are found incidentally, but initial symptoms of abdominal or loin pain are very important. Early acute findings may include tachycardia, hypotension, and severe abdominal pain. Subacute symptoms include flank tenderness, diarrhea, malaise, nausea, and vomiting. Unilateral adrenal hemorrhage may be the initial presentation of an underlying adrenal mass, cyst, coagulopathy or metastasis. Elevated cortisol and catecholamines released by an expanding hematoma are often seen along with elevated blood pressure, suggesting pheochromocytoma. The Hormonal analysis includes urine metanephrine and vanillylmandelic acid to rule out active pheochromocytoma. In our case, the patient had elevated urine metanephrines and normetanephrines suggestive of pheochromocytoma. Presentation: No date and time listed