PP.17.23

Abstract

Objective: Accurate diagnosis of haemodynamic instability is difficult in the emergency department. We need to rule out immediately the life threatening conditions which could evolve with such clinical findings but after, it could be a “long way” to the correct diagnosis. Design and method: A case report with an unexpected cause of orthostatic hypotension. Results: This is the case of a patient aged 73 with newly diagnosed uncomplicated type II diabetes, without known arterial hypertension, who presented in the emergency department with resting tachycardia, occipital headache and clinically significant orthostatic hypotension (faintness, 60mmHg decrease in SBP). In emergency we ruled out subarachnoid hemorrhage, acute hemorrhagic syndrome and pulmonary embolism by chest CT. We also ruled out acute coronary syndrome, atrioventricular or aortic obstruction by echocardiography and laboratory investigations. Orthostatic hypotension is maintained for 48 hours despite aggressive fluid reppletion, the patient relating intermittent episodes of occipital headache, nonspecific chest pain, sweating and flush occurring especially during emotional stress conditions (venipuncture) or mictionary effort. Monitoring BP/24 h reveals values rising to 220/140mmHg with spontaneous remission which rise the suspicion of pheochromocytoma. The dosage of free plasma metanefrines indicate values more than 10 times the upper limit of normal and abdominal CT identified a tumor on the right adrenal looking compatible with pheochromocytoma. Treatment with alpha and beta blockers was started and, after 2 weeks, the patient was referred to surgery. The pathological examination revealed alveolar growth pattern in anastomosed cords and in difuse, solid areas, marked cytological and nuclear pleomorphism of cells, nuclear inclusions, hipercromatism, confirming the diagnosis of pheochromocytoma. The evolution at 1 month was favorable with normalisation of blood pressure values and glycemia. Conclusions: The typical clinical presentation of pheochromocytomas is constant elevated blood pressure or normal blood pressure with significant paroxysm related to variant stimulus. However, in some undiagnosed situations with long evolution, there is an important constriction of the vascular space leading to significant orthostatic hypotension which can further hide the real diagnosis. We appreciate it is worthy to keep in mind this “edge” diagnosis after excluding the most common causes of orthostatic hypotension.