CC
• Pt is a 48 yo AA male who presents with
SOB.
HPI
• SOB has been progressive over the last
couple of weeks. Patient has had
orthopnea, no dyspnea on exertion,
cough productive of white sputum. Patient
denies fever,admits wheezing, denies
pedal edema, denies palpitations, denies
chest pain or pressure.
PMHx
• Pt has had 16 year Hx of HTN, refractory
to multiple medications including, Ace-I,
HCTZ, BB and CCB.
• BPH
FHx
• Diabetes in Father
• Father died of MI
SHx
• Patient has a Hx of cocaine use that
ended 2 years ago.
• Patient currently smokes 1 ppd
ROS
• Claims weight loss of 10 lbs over 1 month
• Constipation for 2 weeks, only broken
miralax, several days ago
Medications and Allergies
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Clonidine
Metoprolol
HCTZ
Amlodipine
• PCN-allergy of rash
PE
• Afebrile, HR 111, BP 203/139, RR 18, SAO2
99% on RA
• A large non-obese AA man AAOX3
• Coughing, speaking complete sentences, in
NAD, mild dyspnea on minimal exertion
• No visible JVD, no pedal edema,
• Taccycardic s1s2, with s4 gallop, no murmur, no
rub
• Good inspiratory effort with reduced breath
sounds on posterior lung fields, no crackles
Labs
Na-134 K-3.9 Cl-95 CO2-23 BUN-13 Cr-1.1
Glu-103 BNP-4054
WBC-12.4 Hg-11.7 Hct-33.8 Plat-287
Troponin=0.06, CKMB=9.0, CK=522
CT chest- no PE, b/l pleural effusions, L
heterogenous mass w/ internal
calcification from adrenal gland
SHOW IMAGE
Differential?
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•
Essential Hypertension
Renal Cell Carcinoma
Cocaine induced HTN
Thyrotoxicosis
Systolic CHF
Diastolic CHF
COPD exacerbation
Pheochromocytoma
Post-renal ARF with fluid overload
Pheochromocytoma
• Definition: a catecholamine secreting
tumor derived from chromaffin cells in
adrenal medulla.
• Epidemiology: no gender difference, 0.05% of
population, incidence at is highest at 30-40 yo.
• Associated with MEN II: Medullary carcinoma, 1
Hyperparathroidism, Pheochromocytoma, (RET
gene)
• Associated with Von Hippel Lindauhemangioblastomas (CNS), retinal angiomas,
renal cysts, clear cell renal carcinoma,
pancreatic cysts, papillary cystadenoma of
epididymus, endolymphatic sac tumors (Von
Hippel Lindau gene)
Symptoms: hypertension 55%, headache
80%, palpitations 70%, hyperhydrosis 60%
Signs of heart failure, high BP, sinus
taccycardia s4 gallop, pulmonary edema,
MR, LVH w/ lateral PMI.
24 hour collection for metanephrines:
100% sensitive
Patient’s: Normetanephrine 20,154 (649)
Metanephrine 105 (203)
Total Metanephrine 20,259 (739)
Plasma [normetanephrine>2.5 pmol/ml] or
[metanephrine>1.4 pmol/ml]
100% specific
We decided to wait for biopsy, also 100% specific
• Scintigraphy w/ 131 I-MIBG (NE analog)
targets to adrenergic tissue
• Clonidine suppression test- clonidine
should no suppress the plasma levels of
NE
• Treatment requires phenoxybenzamine, B
blocker, metyrosine and IV rehydration 14
days prior to surgery
• Surgical Resection
Cardiac Reflections
• Echo 3/2: LV diastolic dysfunction, EF4549%, LV relaxation abnormality.
• Techitium 99 M Stress test 3/4: LVEF
estimated at 29%, global hypokinesis, and
inhomogenous trace uptake, compatible
with dilated cardiomyopathy.
• Cardiac Catheterization: moderately
severe RCA 70%, LV 30%