MON-394 Spontaneous Hemorrhage of Undiagnosed Adrenal Pheochromocytome Following Anticoagulation for Unstable Angina

Abstract

Introduction: Pheochromocytomas are rare catecholamine producing neuroendocrine tumors of the adrenal medulla or extra-adrenal chromaffin tissue with a prevalence of less than 1%. Pheochromocytoma presenting with acute hemorrhage is extremely rare and can be the cause of massive and lethal retroperitoneal hemorrhage. Symptoms are due to periodic catecholamine discharge into the vasculature, mass effect of the lesion or adrenal insufficiency. This report highlights a case of retroperitoneal hemorrhage in a patient with undiagnosed pheochromocytoma who was anticoagulated for unstable angina. Case Report: We present a 41 year old female who was admitted to our hospital due to concern of recurrent episodes of headaches associated with nausea, vomiting and left sided abdominal pain radiating to her chest along with diaphoresis. Her medical history was notable for hypertension, diabetes type 2, CVA and obstructive sleep apnea. In the ER she was noted to have elevated blood pressure and tachycardia with some episodes of bradycardia. Her examination was unremarkable except left sided flank pain. Her labs were unremarkable except acute kidney injury. She had an EKG done which did show some T wave inversions in inferior leads. She was evaluated by CVICU who recommended to start the patient on anticoagulation. She was admitted to the floor for unstable angina and did receive a therapeutic dose of lovenox. After receiving lovenox she developed severe left sided flank pain and elevated blood pressure in the 240/140,s range. In view of severe abdominal pain CT abdomen was done which revealed hemorrhage of left retroperitoneal mass. She was transferred to ICU and started on nicardipine drip for blood pressure control and retroperitoneal bleed was monitored. Given her history of episodic spells of hypertension, diaphoresis and headache combined with retroperitoneal mass, work up for pheochromocytoma was initiated. Patient was noted to have elevated serum metanephrines and normetanephrines with values more than 4 times normal. Patient was started on prazosin for blood pressure control and was discharged home when blood pressure improved with recommendations for blood pressure optimization with medications for 2 weeks prior to surgical intervention. Conclusion: Spontaneous hemorrhage within a pheochromocytoma is rare and it bears medical and surgical challenges because of massive release of catecholamines and hemodynamic instability associated with it. Thus an accurate diagnosis and adequately prepared surgical removal are important for a good postoperative prognosis. This case reinforces the need for maintaining a high index of suspicion for pheochromocytoma in similar cases.