PS-BPR01-10: PHEOCHROMOCYTOMA MASQUERADING AS A LONG-TERM SEVERE ANXIETY DISORDER WITH PANIC ATTACKS REFRACTORY TO PSYCHIATRIC TREATMENT

Abstract

Introduction and Objective: Pheochromocytoma is often diagnosed in the workup of a patient with severe, refractory hypertension, but nowadays many silent pheochromocytomas are diagnosed in the workup of an incidental adrenal mass. Anxiety is also a common symptom in patients with pheochromocytoma and occasionally may be the only clinical manifestation. Hereby we describe the case of a patient with a severe refractory anxiety disorder as a bizarre presentation of pheochromocytoma. Design and Methods: Review of the patient's records and of the relevant literature. Results (Case Description): A 67-year old woman was referred to our Endocrinology Clinic for the workup of an incidental left adrenal mass found in an abdominal CT ordered in the nephrolithiasis workup after a renal colic. The patient had no previous relevant history of somatic disease. She had been suffering from anxiety disorder since she was 50, beginning with climacteric symptoms (hot flashes, irritability and mood swings) followed by severe anxiety, frequent panic attacks, insomnia and inability to concentrate. Hormonal replacement therapy had been ineffective. In the following 17 years she had consulted many public and private psychiatrists and had been treated with combinations of anxiolytic and antidepressant drugs including lormetazepam, clonazepam, bromazepam, vortioxetine, quetiapine, venlafaxine, agomelatine, risperidone, mirtazapine, but the patient's anxiety symptoms kept deteriorating. BP up to 180/110 mmHg and tachycardia up to 130 bpm had been recorded during anxiety crises but ABPM ruled out sustained hypertension or tachycardia. After the finding of the adrenal lesion the diagnostic process was straightforward. It was a solid, heterogeneous mass of about 6 cm diameter, with necrotic areas and mean densitometry of 86 UH. The lab workup showed normal creatinine and potassium, suppressed cortisol after 1 mg dexamethasone, normal ACTH, aldosterone, renin and aldosterone/renin ratio, but plasma metanephrines were above 5x the upper normal limit (634/2423 pg/mL). A MIBG scan confirmed intense uptake in the left adrenal area without abnormal extra-adrenal deposits. After standard preparation, the tumor was laparoscopically removed without complications. 1 month after the surgery plasma metanephrines were normal and the anxiety symptoms had vanished almost totally, but the patient kept taking a low dose of risperidone (1.5 mg/day) as a maintenance therapy; BP and HR remained normal Conclusions: Pheochromocytoma/paraganglioma should be included in the workup of patients with severe anxiety disorder, especially when refractory to treatment.