Classic Triad Of Headache Research Articles

'Great Masquerader': a history of diagnosing pheochromocytoma.

Pheochromocytoma is a unique tumour with a variety of clinical presentations. Coined as 'the great masquerader', it can present with the classical triad of headache, sweating and tachycardia and sometimes in an acute hypertensive crisis. This paper describes the evolutionary history of the diagnosis of this condition. A literature review was conducted using Medline Database from 1900 to 2023 outlining the methods of diagnosis for pheochromocytoma. There have been diagnostic dilemmas and localization challenges of pheochromocytoma over the last century. From the first description of pheochromocytoma in 1886 to the first successful resection in 1926, there was poor recognition of its atypical symptoms and lack of reliable diagnostic tests. Over the next few decades, there were significant advances in screening and biochemical tests. Further understanding of catecholamine release and metabolic pathways led to the development of tests to identify end products of catecholamine metabolism in plasma and urine. Computed imaging however heralded significant improvement in surgical planning and management. The evolution of histopathological diagnosis with the use of immunostains and genetic testing has further contributed to the identification of malignant pheochromocytomas and an understanding of their behaviours. Significant advances in the biochemical and imaging have shaped our understanding of pathophysiology and management. These diagnostic advances have enabled early and accurate detection and localization of pheochromocytomas to enable prompt surgical management.

Pheochromocytoma: Clinical Experience From a Single Tertiary Care Center in India.

Pheochromocytoma is a catecholamine-secreting tumor arising from adrenomedullary chromaffin cells that has a varied clinical presentation. Identification of this tumor, which has episodic symptoms, is a diagnostic challenge for clinicians. Diagnosis at an appropriate time is important because it is associated with significant morbidity and mortality. This study aims to mitigate the limited availability of data in our geographical area. To assess the clinical, biochemical, and radiological features and outcomes of patients diagnosed with pheochromocytoma at our center. This is a retrospective study. Patients diagnosed with pheochromocytoma during 2015-2023 were included in the study. Clinical, biochemical, and radiological data were collected at presentation, post-surgery, discharge, and until the last follow-up; data were retrieved from hospital records. Statistical analysis was done using IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp. This study included 19 patients, of whom 10 (52.6%) were female. The most common clinical presentation was a hypertensive crisis in patients with pre-existing hypertension (63.1%), followed by headache (47.3%). The classical triad of headache, palpitation, and sweating was seen in only three patients (15.7%). The mean tumor size was 5.01±2.06 cm, with a range of 2.5 to 12 cm. All patients underwent adrenalectomy; six patients (31.5%) had perioperative complications, with post-operative hypotension being the most common at 21% (n = 4), followed by an acute coronary event during alpha blockade in one patient (0.05%) and an intra-operative hypertensive crisis in one patient (5%). A biochemical remission rate post-surgery was achieved in 17 (89.47%) patients. Hypertensive crisis in patients with pre-existing hypertension was the predominant presenting feature in most of our patients. Female predominance was noted (52.3%) compared to males. Perioperative complications were observed in 31.5% of patients, with post-operative hypotension being the most common complication.

PSUN23 Clinical and Surgery Approach in Pheocromocytomas: A Cross-Sectional Study at a Referral Center in Ecuador

Abstract Background An annual incidence of pheochromocytoma (PHEO) has been reported between 0.4 to 9.5 cases per million inhabitants and a prevalence of 2.13 per 100 000 people. More than 40% of patients have a genetic predisposition, and its presentation is heterogeneous, from incidental findings (10-49%) to prominent clinical pictures attributable to hypersecretion of catecholamines. The epidemiological and descriptive studies referring to pheochromocytomas in South America are scarce. This study aimed to show a retrospective analysis of patients with pheochromocytomas attending in a cancer referral center to determine the clinical, histology, and surgery outcomes. Methods From January 2015 to December 2021, a cross-sectional study was conducted in a regional reference public hospital for endocrine neoplasia in adults. We identified the clinical manifestations, pharmacologic and surgical treatment modalities from a patient interview and review of clinical records. Results Twelve patients were included, with a mean age of 44.9 (SD 10.5) years old. Around 58.3% (n=7) of the patients were male, and 16.6% (n=2) had a family history of MEN2A. Clinical characteristics of PHEO were identified in 83.3% (n=10) of the patients. The most common clinical presentation included: hypertension 10/12, palpitations and headache 9/12, diaphoresis and dyspnea 8/12, abdominal pain, nausea, and vomiting 7/12, and sensation of heat and dizziness 6/12. The classic triad of headache, palpitations, and sweating was observed in 8 patients. The CT image revealed adrenal tumors in the left (n=7/12), right (n=4/12), and one bilateral. The mean tumor diameter was 70.5 mm (SD +39.8 range 38 - 180 mm), and 91.7% of the patients (n=11/12) had tumors ≥ 4 cm. Most of the patients, 54.5%, underwent a laparoscopy procedure (n=6/11). In 2 cases, the procedure was converted to open surgery. The mean operative time was 201 ± 77.2 min. After surgery, all patients were admitted to the intensive care unit, where 75% (n=9/11) required vasoactive therapy with satisfactory recovery. The postoperative outcome showed 81.8% with normal blood pressure (n=9/11). Conclusion Most patients presenting to our hospital had large intra-abdominal tumors with a high cure rate and low mortality. Accurate diagnosis and optimal treatment are best achieved at 'centers of excellence' with expert multidisciplinary teams. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Clinical characteristics and outcome of primary brain abscess: a retrospective analysis

BackgroundPatients with primary brain abscess often present with atypical symptoms, and the outcome varies. We investigated the demographic, laboratory, and neuroimaging features of patients with brain abscess at our hospital and identified factors associated with their outcomes.MethodsWe retrospectively collected the data of patients diagnosed with primary brain abscess at our hospital between January 2011 and December 2020. Their clinical characteristics, predisposing factors, laboratory and neuroimaging findings, treatment, and outcome were analyzed.ResultsOf the 57 patients diagnosed with primary abscess, 51 (89.47%) were older than 40 years, and 42 (73.68%) were male. Only eight patients (14.04%) showed the classical triad of headache, fever, and focal neurological deficit. Fifteen patients (26.31%) had comorbidities, of which diabetes mellitus was the most common. Positive intracranial purulent material cultures were obtained in 46.15% of the patients, and gram-negative enteric bacteria were found in 33.33% of them, with Klebsiella pneumoniae being the most frequently observed. Surgical treatment, most commonly in the form of stereotactic drainage, was received by 54.39% of the patients. Good outcomes were achieved in 75.44% of the patients. Multivariate logistic regression analysis showed that patients with headaches were more likely to have a poor outcome (odds ratio 6.010, 95% confidence interval 1.114–32.407, p = 0.037).ConclusionsMale patients and those older than 40 years were more susceptible to brain abscess than female patients and those younger than 40 years, respectively. Only a few patients showed the classical triad of clinical symptoms. Diabetes mellitus was the most common comorbidity. Positive intracranial specimens’ culture results were uncommon, with gram-negative enteric bacteria, especially Klebsiella pneumoniae, being the main organisms found. Most patients had a good outcome, and the presence of headache may influence the outcome.

Functional and non-functional types of adrenal tumors: a case series

Adrenal gland masses could be classified into functional, malignant, or benign. An adrenal cortical adenoma is one of the most common incidentalomas found with either functional or non-functional type. Pheochromocytoma is a neural crest cell origin tumor associated with catecholamine production. A classic triad of headache, sudden episodic perspiration, and tachycardia marked a pheochromocytoma. We report three patients with adrenal tumors. First, a 52-year-old woman with complaints of pain in the left flank suggests a left kidney tumor. The patient has an increased blood pressure intraoperatively. Adrenal cortical adenoma was found postoperatively. The second case is an Indonesian male 27-year-old with pain in the upper right abdomen. Intraoperative, the patient also has an escalation in blood pressure. Antihypertensive drugs are also used in this patient. Postoperatively, a pathology result of pheochromocytoma was revealed from this patient. The third case, adrenal myelolipoma, was suspected in a 48-year-old male and underwent surgery because of tumor growth. Later, a histopathological examination revealed myelolipoma of the adrenal. Management of adrenal tumor should be done individually based on each patient. In the first and second cases, blood pressure was unstable intraoperatively and was managed using several drugs, and was stable at follow-up. In the third case was no hemodynamic problem. In the case of an adrenal tumor, management tailoring should be based on the individual patient.

Feocromocitoma: Cirugía urgente vs Cirugía programada

El feocromocitoma es un tumor de células cromafines localizado preferentemente en la cavidad abdominal y en particular en la glándula suprarrenal. Clínicamente puede ser asintomático o presentarse con una amplia variedad de síntomas, dada su capacidad de secretar catecolaminas, tales como hipertensión arterial junto con la triada clásica de cefalea, hiperhidrosis y taquicardia. A continuación, presentamos un caso clínico de un paciente de sexo masculino, de 24 años, que debuta con pérdida de fuerza en extremidades derechas tras crisis hipertensiva y hematoma en ganglios basales, al cual se tiene que intervenir de urgencia bajo la sospecha de tumor feocromocitoma, con posterior diagnóstico, preparación prequirúrgica meticulosa y cirugía programada del mismo.

What you need to know about brain abscesses.

A brain abscess is a focal accumulation of pus in the brain parenchyma arising from direct inoculation, contiguous spread from local anatomical structures or haematogenous seeding from a remote source of infection. It can result in significant morbidity and mortality, making early diagnosis and treatment vital. Only one fifth of patients present with the classic triad of headache, fever and focal neurological symptoms. More commonly patients show signs and symptoms of raised intracranial pressure alone, such as confusion or reduced conscious level, headache, nausea and vomiting, which can be a presentation of many intracranial pathologies. Distinguishing an abscess from other pathologies such as meningitis and tumours is crucial, as clinically these can present in similar ways, but their management and outcomes are very different. Diffusion-weighted magnetic resonance imaging brain scans can help localise the lesion and differentiate ring-enhancing lesions caused by a brain abscess from malignant tumours. Cerebral abscesses are considered a neurosurgical emergency; early stabilisation, diagnosis and management in a neurosurgical centre is important in reducing morbidity and mortality.

SUN-924 Functioning Abdominal Paraganglioma Presenting as Acute ST-Elevation Myocardial Infarction

Background:Functioning paraganglioma is a rare catecholamine-producing tumor that arises in the sympathetic nervous system. It usually presents with sustained or paroxysmal hypertension accompanied by episodes of its classic triad of headache, palpitation, and diaphoresis. However, a wide range of signs and symptoms may be present. We report an unusual manifestation as acute myocardial infarction, which accidentally diagnosed by the trigger response from metoclopramide injection.Case presentationA 66-year-old woman with medical history of well-control hypertension, dyslipidemia and type 2 diabetes mellitus for 8 years presented with typical angina pain for 1 hour. She denied history of chest pain or triad symptoms of pheochromocytoma/paraganglioma (PCC/PGL). Her physical examination was unremarkable except severe hypertension, 206/89 mmHg, and occasional sinus tachycardia. Acute inferior wall myocardial infarction was proposed by an electrocardiogram study, acute ST elevation in lead II, III and aVF, and highly elevated cardiac enzymes. Echocardiogram and coronary angiography showed preserved left ventricle function (LV ejection fraction 70%) without regional wall motion abnormality. No evidence of coronary artery disease was found. During the catheterization, the cardiologist raised the possibility of the presence of PCC/PGL from her fluctuating blood pressure, 73/42 to 206/113 mmHg, after 10-mg metoclopramide injection to control her vomiting. Computer tomography of the abdomen showed a lobulated heterogeneous enhancing left para-aortic mass with internal necrosis, 6.1x4.9x4.1 cm in size, abutting left anterolateral aortic wall and encasing celiac trunk, superior mesenteric artery, and left renal arterial wall. Her hormonal study showed 24-hour urine fractionated metanephrine/normetanephrine levels of 2,924 nmol (<1,777 nmol)/4,328 nmoL(< 3,279 nmol), respectively, and plasma free metanephrine/normetanephrine levels of 93.66 pg/mL (0-96.6 pg/mL)/233.61 pg/mL (0-163.05 pg/mL). She underwent surgical tumor removal with uneventful outcome and the pathology confirmed the diagnosis of functioning PGL. During 2-years follow-up, the patient remained asymptomatic and her hormonal and functioning imaging study showed no recurrence. The genetic testing for PCC/PGL panel was negative.Conclusion:We present an unusual manifestation of PCC/PGL as acute coronary syndrome. The clinician should remind this tumor as the differential diagnosis, especially in a patient with negative coronary angiogram.

MON-LB041 Pheochromocytoma - Illusive Myriad of Symptoms

Background: Pheochromocytoma is a rare neuroendocrine neoplasm arising from the adrenal medullary chromaffin cells. It contributes to 80-85% of catecholamine secreting tumors. The annual incidence of pheochromocytoma is 0.8 cases per 100,000 person-years. It can be both sporadic or familial. The classic triad of headache, palpitations and diaphoresis is seen in only 4% of cases. Rare presentations include cardiomyopathy, stroke, diabetes mellitus, ventricular arrhythmias and myocardial infarction. Our patient presented concurrently with dilated cardiomyopathy, hypertensive emergency and new-onset diabetes mellitus (DM) followed by ischemic stroke within a week. Heart failure can present as takotsubo or dilated cardiomyopathy with an incidence of 10%. The underlying pathophysiology is catecholamine mediated myocardial stunning, diffuse coronary vasospasm, microvasculature dysfunction and fibrosis. DM is seen in 23% of pheochromocytoma and is due to catecholamine-induced impaired glucose tolerance, and insulin resistance. Cerebral ischemia has an incidence of 3%, and is secondary to severe hypertension and cerebral vasospasm. Clinical Case: A 47-year-old African American woman presented with a 1-week duration of worsening dyspnea, orthopnea, dizziness, and palpitations. Past medical history includes HTN, non-ischemic cardiomyopathy on carvedilol and pravastatin. Physical exam: BP 182/119, HR 120, mild pulmonary crackles. Labs: proBNP 3533 (1-150 pg/ml), HbA1c 13.1%. Echocardiogram: moderate global hypokinesis with left ventricle ejection fraction (LVEF) of 30-35%. On imaging, CT of chest revealed an incidental finding of 4.7 cm right adrenal adenoma. MRI abdomen confirmed heterogeneously enhancing 4.3 cm right adrenal mass. Further testing showed high plasma catecholamines of 9963 (242-1125 pg/ml), 24-hour urine catecholamines of 2125 (50-100 mcg), thus confirming the diagnosis of pheochromocytoma. Further, her clinical course was complicated by left-sided weakness. MRI brain reported an acute infarct in right corona radiata. Pre-operative blockade was done with phenoxybenzamine and metoprolol. Subsequently, she underwent right adrenalectomy and tissue diagnosis confirmed pheochromocytoma. On follow up visit, her symptoms resolved. Also noted normalized catecholamine levels, HbA1c of 5.4% and LVEF of 40- 45%. Conclusion: Pheochromocytoma can rarely present with multi-organ failure. It warrants a high index of suspicion in non-ischemic cardiomyopathy. As per recent Mayo Clinic criteria, diagnosis of takotsubo cardiomyopathy mandates ruling out pheochromocytoma. As seen in our patient, it is a reversible cause of left ventricular dysfunction, focal weakness and DM. Based on our knowledge, this is the only contingently diagnosed pheochromocytoma with varied clinical presentations. It has been aptly described as “The Great Masquerader”.

Unusual presentation of pheochromocytoma: thirteen years of anxiety requiring psychiatric treatment

SummaryPheochromocytoma is a rare tumor of the adrenal gland. It often presents with the classic triad of headache, palpitations and generalized sweating. Although not described as a typical symptom of pheochromocytoma, anxiety is the fourth most common symptom reported by patients suffering of pheochromocytoma. We report the case of a 64 year old man who had severe anxiety and panic disorder as presenting symptoms of pheochromocytoma. After 13 years of psychiatric follow-up, the patient was diagnosed with malignant pheochromocytoma. After surgical resection of his pheochromocytoma and his hepatic metastases, the major panic attacks completely disappeared, the anxiety symptoms improved significantly and the psychiatric medications were stopped except for a very low maintenance dose of venlafaxine. We found in our cohort of 160 patients with pheochromocytoma 2 others cases of apparently benign tumors with severe anxiety that resolved after pheochromocytoma resection. These cases highlight that pheochromocytoma should be included in the differential diagnosis of refractory anxiety disorder.Learning points:Anxiety and panic disorder may be the main presenting symptoms of pheochromocytoma.The diagnosis of pheochromocytoma should be excluded in cases of long-term panic disorder refractory to medications since the anxiety may be secondary to a catecholamine-secreting tumor.Surgical treatment of pheochromocytoma leads to significant improvement of anxiety disorders.

A study on the clinical outcomes and management of meningitis at a tertiary care centre.

Meningitis is a life threatening central nervous system infection that is prevalent worldwide. Many studies have been conducted on bacterial meningitis, but the information is inadequate on the other types of meningitis, especially prevalent in India. Regional information regarding trends, in terms of etiology and microbiological susceptibility, are essential for timely and adequate management of meningitis. The present study was undertaken to evaluate the changing epidemiology of meningitis by reviewing the causative agents, the available laboratory methods for making the etiological diagnosis, the risk factors and the clinical outcomes, and the management of meningitis in our patient population. It is an observational study conducted at a tertiary care centre. A structured data form was designed to collect the information from the medical records and charts of medical investigations of the patients. Details regarding etiological agents, prevalence of clinical features and management were recorded and interpreted. A total of 147 patients suspected to be having meningitis were included. The common types of meningitis in our study were aseptic (39%), tuberculous (28%), pyogenic (28%), fungal (3%) and others (2%). The classical triad of headache with fever, neck stiffness, and altered mental sensorium was seen in 26% patients, and 83% had at least 2 out of these 4 symptoms. The incidence of seizures was found to be 63% in the presence of aseptic meningitis. Significant clinical improvement was seen in 89% of the patients suffering from aseptic meningitis. Aseptic meningitis was found to be the predominant type among all different varieties of meningitis. An increased incidence of meningitis was seen in patients with diabetes mellitus. The incidence of seizures was high in viral/aseptic meningitis. The empirical treatment given in most of the cases was ceftriaxone. Isolation of the culpable organisms was possible in a very few cases due to the usage of empirical antibiotics prior to the performance of the lumbar puncture for the diagnostic analysis of the cerebrospinal fluid.

Bifrontal brain abscesses secondary to orbital cellulitis and sinusitis extension.

BackgroundIntracranial abscesses are rare and life-threatening conditions that typically originate from direct extension from nearby structures, hematogenous dissemination or following penetrating cerebral trauma or neurosurgery.FindingsA 36-year-old male presented to our emergency department with complaints of left eye swelling, headache and drowsiness. On physical exam, the patient was febrile and his left upper eyelid was markedly swollen with fluctuance and drainage. Maxillofacial computed tomography was obtained to evaluate for orbital pathology but revealed bifrontal brain abscesses.ConclusionsBrain abscesses should be considered in the differential diagnosis for patients who present with the classic triad of headache, fever and neurological deficit.

Does this patient have Pheochromocytoma? a systematic review of clinical signs and symptoms.

ContextPheochromocytoma is a rare disease but with high mortality if it is not being diagnosed early. Several biochemical tests with high accuracy have been obtained, but the clinical threshold for request of these tests is not determined clearly.ObjectivesTo determine the Likelihood Ratios of clinical symptoms and signs in diagnosing pheochromocytoma. And also meta-analysis of their sensitivity in this disease.Data sourcesMEDLINE was searched for relevant English-language articles dated 1960 to February 2014. Bibliographies were searched to find additional articles.Study selectionWe included original studies describing the sensitivity and/or likelihood ratios of signs and symptoms in clinical suspicion of pheochromocytoma. Their method of diagnosis should have been based on pathology. We excluded specific subtypes or syndromes related to pheochromocytoma, or specific ages or gender. Also we excluded studies before 1993 (JNC5) which no definition of hypertension was presented. 37 articles were chosen finally.Data extractionTwo authors reviewed data from articles independently and gave discrepancies to third author for decision. The aim was extraction of raw numbers of patients having defined signs or symptoms, and draw 2 × 2 tables if data available. We meta-analyzed sensitivities by Statsdirect and Likelihood Ratios by Meta-disc soft wares. Because our data was heterogeneous based on I2 > 50 % (except negative Likelihood ratio of hypertension), we used random effect model for doing meta-analysis. We checked publication bias by drawing Funnel plot for each sign/symptom, and also Egger test.Data synthesisThe most prevalent signs and symptoms reported were hypertension (pooled sensitivity of 80.7 %), headache (pooled sensitivity of 60.4 %), palpitation (pooled sensitivity of 59.3 %) and diaphoresis (pooled sensitivity of 52.4 %). The definition of orthostatic hypotension was different among studies. The sensitivity was 23–50 %.Paroxysmal hypertension, chest pain, flushing, and weakness were the signs/symptoms which had publication bias based on Funnel plot and Egger test (P value < 0.05). Seven of the articles had control group, and could be used for calculating LR of signs/symptoms. Diaphoresis (LR+ 2.2, LR-0.45), Palpitation (LR+ 1.9, LR-0.52) and headache (LR+ 1.6, LR-0.24) were significant symptoms in clinical diagnosis of pheochromocytoma. Other signs and symptoms had been reported in only one study and could not have been meta-analyzed. Classic triad of headache, palpitation and diaphoresis in hypertensive patients had the LR+ 6.312 (95 % CI 0.217–183.217) and LR-0.139 (95 % CI 0.059–0.331). Surprisingly, hypertension was not important in clinical suspicion of pheochromocytoma, and even normotension increased the probability of the disease.ConclusionsBy available data, there is no single clinical finding that has significant value in diagnosis or excluding pheochromocytoma. Combination of certain symptoms, signs and para-clinical exams is more valuable for physicians. Further studies should be done, to specify the value of clinical findings.Until that time the process of diagnosis will be based on clinical suspicion and lab tests followed by related imaging.

Does this patient have pheochromocytoma? A systematic review of clinical signs and symptoms.

ContextPheochromocytoma is a rare disease but with high mortality if it is not being diagnosed early. Several biochemical tests with high accuracy have been obtained, but the clinical threshold for request of these tests is not determined clearly.ObjectivesTo determine the Likelihood Ratios of clinical symptoms and signs in diagnosing pheochromocytoma. And also meta-analysis of their sensitivity in this disease.Data sourcesMEDLINE was searched for relevant English-language articles dated 1960 to February 2014. Bibliographies were searched to find additional articles.Study selectionWe included original studies describing the sensitivity and/or likelihood ratios of signs and symptoms in clinical suspicion of pheochromocytoma. Their method of diagnosis should have been based on pathology. We excluded specific subtypes or syndromes related to pheochromocytoma, or specific ages or gender. Also we excluded studies before 1993 (JNC5) which no definition of hypertension was presented. 37 articles were chosen finally.Data extractionTwo authors reviewed data from articles independently and gave discrepancies to third author for decision. The aim was extraction of raw numbers of patients having defined signs or symptoms, and draw 2 × 2 tables if data available. We meta-analyzed sensitivities by Statsdirect and Likelihood Ratios by Meta-disc soft wares. Because our data was heterogeneous based on I2 > 50 % (except negative Likelihood ratio of hypertension), we used random effect model for doing meta-analysis. We checked publication bias by drawing Funnel plot for each sign/symptom, and also Egger test.Data synthesisThe most prevalent signs and symptoms reported were hypertension (pooled sensitivity of 80.7 %), headache (pooled sensitivity of 60.4 %), palpitation (pooled sensitivity of 59.3 %) and diaphoresis (pooled sensitivity of 52.4 %). The definition of orthostatic hypotension was different among studies. The sensitivity was 23–50 %.Paroxysmal hypertension, chest pain, flushing, and weakness were the signs/symptoms which had publication bias based on Funnel plot and Egger test (P value < 0.05). Seven of the articles had control group, and could be used for calculating LR of signs/symptoms. Diaphoresis (LR+ 2.2, LR- 0.45), Palpitation (LR+ 1.9, LR- 0.52) and headache (LR+ 1.6, LR- 0.24) were significant symptoms in clinical diagnosis of pheochromocytoma. Other signs and symptoms had been reported in only one study and could not have been meta-analyzed. Classic triad of headache, palpitation and diaphoresis in hypertensive patients had the LR+ 6.312 (95 % CI 0.217–183.217) and LR- 0.139 (95 % CI 0.059–0.331). Surprisingly, hypertension was not important in clinical suspicion of pheochromocytoma, and even normotension increased the probability of the disease.ConclusionsBy available data, there is no single clinical finding that has significant value in diagnosis or excluding pheochromocytoma. Combination of certain symptoms, signs and para-clinical exams is more valuable for physicians. Further studies should be done, to specify the value of clinical findings. Until that time the process of diagnosis will be based on clinical suspicion and lab tests followed by related imaging.

Pheochromocytoma Anesthetic Management

Pheochromocytomas are catecholamine producing tumors and although uncommon present a great challenge to the anesthesiologist since it has nonspecific clinical symptoms and risk of critical events, including death when not previously diagnosed. Clinical manifestation is variable, unspecific and depends on the catecholamine production profile. The classic triad of headache, palpitation and diaphoresis is present in up to 70% of the cases and only 50% have sustained hypertension. The best approach for pheochromocytoma treatment is surgical excision of the affected adrenal gland. The introduction of alpha adrenergic blockade medication, such as phentolamine and phenoxybenzamine had the highest impact in perioperative mortality reduction due to inhibition of the deleterious effect of vasoconstriction. The majority of anesthetic techniques and drugs are considered safe. Post-operative care in intensive care unit is advisable since patients may present instability of blood pressure and hypoglycemia. Genetic testing should be done in first-degree relatives of confirmed cases or when a genetic syndrome is suspected.

A Not So Simple Retroperitoneal Mass-A Clue from Hypertensive Crisis

Extra adrenal paragangliomas are tumours of chromaffin cells arising from the sympathetic and parasympathetic divisions of the autonomic nervous system. About 75% of them are located between the origin of the inferior mesentric artery and bifurcation of the abdominal aorta known as the organ of Zuckerkandl.1Their clinical presentations are varied and are mostly due to the excessive secretion of catecholamines by the tumour. The incidence of the classic triad of Headache, Palpitations and Diaphoresis is seen in as little as 24% of cases. 2A recent review reports hypertension to be paroxysmal in 48%, persistent in 29% and absent in 13 % of cases. 2 About 49% of cases are incidentally diagnosed during abdominal imaging. 2 These tumours may be confused with other common retroperitoneal neoplasms, especially when the patient is asymptomatic. We report a severe hypertensive crisis in such an asymptomatic patient, which was triggered on induction of anesthesia and manipulation of the tumour and its successful management in a patient with undiagnosed paraganglioma.

Clinically silent chromaffin-cell tumors: Tumor characteristics and long-term prognosis in patients with incidentally discovered pheochromocytomas

Chromaffin-cell tumors (CCT), a rare group of catecholamine producing endocrine neoplasms, are traditionally suspected and diagnosed in patients presenting with episodic hypertension, together with the classic triad of headache, sweating, and tachycardia. Asymptomatic CCT are increasingly diagnosed, frequently as "incidentalomas". We have conducted a multicenter retrospective study, to assess the characteristics of a group of patients with clinically silent CCT, compared with a group of patients with typical CCT. Forty-three consecutive patients with CCT (24 with silent and 19 with typical tumors) have been retrospectively studied for a period of up to 20 yr (between 1989 and 2009); clinical picture, biochemical tests, as well as topographic and functional assessment were analyzed at diagnosis and periodically following treatment. Surgical samples were reviewed for neuroendocrine markers and for signs of invasiveness. Patients with clinically silent CCT were significantly older than the typical ones (56.3±3.4 vs 48.0±4.8 yr; p<0.05); 15 of them (63%) were completely asymptomatic, and 9 patients (37%) complained of non-specific abdominal symptoms. Hypertension was present in only 6 silent CCT patients (25%), it was well controlled [mean blood pressure (BP) 134/84 mmHg], and persisted after surgery in only 2 patients. Fourteen out of twenty-four silent CCT patients (58%) were managed pre-operatively with prophylactic combination of α and β blockade, despite normal BP values. Clinically silent CCT were larger than typical CCT (mean diameter of 5.2±2.3 cm vs 4.6±1.5 cm, p<0.05) and secreted higher a mounts of normeta neph rines. All clinically silent CCT patients were defined as "cured" after surgery. Clinically silent CCT are more prevalent than previously reported. With an adequate pre-surgical diagnosis and patient preparation, the prognosis of silent tumors is usually excellent.

Lumbar Punctures for Suspected Meningitis in Adults

Objectives: To describe the incidence and etiology of meningitis among patients presenting to the emergency department (ED) who undergo lumbar puncture (LP) and to describe clinical criteria to select which adult patients would not need an LP because the likelihood of meningitis is low. Materials and Methods: This was a retrospective chart review of the results of LPs performed in a tertiary care ED from March to October 2003 on patients aged 16 to 50 years suspected of having meningitis. Using the electronic record, we recorded presenting symptoms, comorbidities, results of (cerebrospinal fluid) analysis, ED length of stay, and complications. The association between specific physical examination or laboratory findings and meningitis was determined through the calculation of sensitivity, specificity, and negative/positive predictive values. Results: Data from the results of 164 LPs were analyzed. Eleven patients (6.7%) had meningitis confirmed by gram stain, culture, or DNA analysis. The causative agents included 55% viral (2 enterovirus, 2 herpes simplex virus, 1 varicella, and 1 coxsackie), 27% bacterial (1 coagulase-negative Staphylococcus aureus, 1 rickettsial, and 1 syphilis) and 18% parasitic/fungal (1 cysticercosis and 1 Cryptococcus neoformans). The most common presenting symptoms or comorbidities in patients receiving an LP were headache (75.6%), fever (47.6%), neck pain or stiffness (23.8%), HIV (11.6%), a history of migraine headaches (4.9%), or a history of cancer or chemotherapy (4.9%). No combination of clinical criteriaVincluding the absence of the classic triad of headache, neck stiffness, and altered mental statusVruled out meningitis. Cerebrospinal fluid findings such as pleocytosis and lymphocytic predominance were strongly associated with meningitis (P = 0.0003 and 0.0004, respectively). Patients receiving an LP stayed in the ED 48.6% longer than other ED patients, and 10 patients (6.1%) returned to the ED within 1 week complaining of headache. Conclusions: In this study, no clinical criteria were identified to select which adult patients would not need an LP because the likelihood of meningitis is low. The absence of fever, neck stiffness, and altered mental status did not rule out adult meningitis. More research may be needed to evaluate the need for adding antiviral agents to the standard regimen when treating presumptive meningitis on adults in the ED. More research is needed to risk stratify adult patients and improve the utilization of LPs in the ED. (Infect Dis Clin Pract 2008;16:298Y302)

Rocky Mountain spotted fever

Rocky Mountain spotted fever (RMSF) is an unusual but important dermatological condition to identify without hesitation. The classic triad of headache, fever, and a rash that begins on the extremities and travels proximally to involve the trunk is found in a majority of patients. The cutaneous centripetal pattern is a result of cell to cell migration by the causative organism Rickettsia rickettsii. Such individuals should receive prompt antimicrobial therapy and supportive care to avoid serious and potentially fatal complications.

Multiple brain abscesses: A case report

10 days before admission a 45-year old female experienced general weakness, and T 38 degrees C. During that period she had no cardio-respiratory nor neurological complaints, and the temperature varied between 37.5 degrees C and 38 degrees C. Her medical history was unremarkable, without immunodeficiency. The day before admission she presented with left arm paresis and during the next day it progressed to paralysis. She had no headache. On admission the following diagnostic procedures were performed: the cranial CT scan showed two lesions (possibly meta lesions). Chest X-ray was normal. WBC=15x10(9)/L, ESR=90/120. On the second day following admission brain MRI showed multiple abscesses in both hemispheres, mostly in the gray/white junction. High doses of IV metronidasol, cephtriaxon and cipfloxacin were administered without obtaining specimens for micro-biological diagnosis. In next two days she developed coma, respiratory insufficiency and septic temperature. Brain surgery was not performed due to severe involvement of the brain with multiple abscesses. Repeated chest X-ray revealed bilateral pneumonia. A lethal outcome occurred on the third day, regardless of all efforts. Autopsy showed multiple brain abscesses as well as on the lungs and liver. A beta-hemolytic streptococcal infection was established. Prevention includes treatment of the infection source. The classic triad of headache, fever and focal deficit occur in less than 50% of patients. Even in such cases brain abscess must be reconsidered CT appearance of brain abscess is similar to that of neoplastic and other infectious and non infectious diseases--especially in the stage of early cerebritis. If the CT findings are not clear, MRI should be performed.