UNSUSPECTED CAUSES OF HYPERTENSION

Abstract

TOPIC: Lung Pathology TYPE: Medical Student/Resident Case Reports INTRODUCTION: Pheochromocytomas (PC) are catecholamine-secreting tumors that arise from the chromaffin cells of the adrenal medulla and other extra-adrenal sources. The annual incidence of PC is approximately 0.8 per 100,000 person-years, however this is thought to be an underestimation as a substantial portion of PC's were diagnosed at autopsy (Beard et al). With the relative rarity of this disease coupled with its often-complicated presentation, it is not uncommon to see this disease misdiagnosed. CASE PRESENTATION: We present a 68-year-old Caucasian female with a past medical history significant for chronic tobacco use, hypertension, hypothyroidism secondary to partial thyroidectomy, coronary artery disease, paroxysmal atrial fibrillation, periodic headaches, backpain and dizziness who presented after a fall at home. An elevated troponin with normal EKG led to treatment for NSTEMI. CT head returned within normal limits and a cardiac catheterization revealed LVEF of 35-40% with 60% mid-LAD stenosis and Coreg and Ramipril were started. A few weeks later, she presented to the ED again with chest pain radiating between her shoulder blades. A CTA chest was significant for a 1.7cm soft tissue density in the right lower lung lobe and a 1.6cm right adrenal nodule. A follow-up PET/CT showed a peak SUV (standardized uptake value) of 1.6 in the lung nodule and a peak SUV of 2 in the adrenal gland nodule. Biopsy of the lung nodule via bronchoscopy was unattainable due to its small size and anatomic location. The decision to proceed to a CT-guided needle biopsy of the right adrenal mass was made with pathology returning consistent with a PC. Further evaluation included measurement of urine metanephrines, which returned elevated. Due to continued suspicion of the right lower lobe nodule likely representing an unrelated, early-stage bronchogenic carcinoma, cardiothoracic surgery consultation was obtained. Pathology of the right lower lobectomy with lymph node biopsies returned consistent with adenocarcinoma of likely lung primary origin. DISCUSSION: It is estimated that approximately 0.2-0.6% of patients with hypertension have a concurrent PC (Omura et al). In fact, approximately 15-30% of the population of hypertensive patients have secondary hypertension and resistant hypertension was noted in approximately 34% of hypertensive patients in the ALLHAT trial (Koch et al). This patient's presentation attests to the semi-cryptic nature of PC. CONCLUSIONS: This case also demonstrates that, despite a suspected cardiac etiology and incidental pulmonary malignant process, searching for the overall causation of the patients presenting symptoms may be more difficult than it first appears. After completing a secondary hypertension workup (as well as dietary and lifestyle changes) with unremarkable results it is important to consider endocrinopathies as an underlying cause, despite their rarity. REFERENCE #1: Beard CM, Sheps SG, Kurland LT, Carney JA, Lie JT. Occurrence of pheochromocytoma in Rochester, Minnesota, 1950 through 1979. Mayo Clin Proc. 1983 Dec;58(12):802-4. PMID: 6645626. REFERENCE #2: Omura M, Saito J, Yamaguchi K, et al. Prospective Study on the Prevalence of Secondary Hypertension among Hypertensive Patients Visiting a General Outpatient Clinic in Japan. Hypertens Res. 2004;27(3):193–202. REFERENCE #3: Koch C, Papadopoulou-Marketou N, Chrousos GP. Overview of Endocrine Hypertension. 2020 Feb 4. In: Feingold KR, Anawalt B, Boyce A, Chrousos G, de Herder WW, Dungan K, Grossman A, Hershman JM, Hofland J, Kaltsas G, Koch C, Kopp P, Korbonits M, McLachlan R, Morley JE, New M, Purnell J, Singer F, Stratakis CA, Trence DL, Wilson DP, editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000–. PMID: 25905214. DISCLOSURES: No relevant relationships by David Heintze, source=Web Response no disclosure on file for Billy Rosson