The Silent Tension: A Case of Pheochromocytoma

Document Type

Abstract

Publication Date

9-1-2025

Abstract

Description: Background/Objective: Pheochromocytoma is a rare endocrine disease, with incidence rates per 100 000. Classic findings include hypertension, palpitations, and headaches. Typical signs can be absent in some cases. Case Report: A 51-year-old woman with a history of anxiety with depression on buspirone and aripiprazole presented for follow-up of adrenal nodule. Prior imaging of 2017 showed a nodule 1.1 cm, which had grown to 2.2 cm in 2022. She denied prior history of hypertension and is not on any antihypertensive medications. She has reported episodes of orthostatic hypotension but denies episodes of sweating, palpitations, or chest pain. She reported intermittent headaches but denied cushingoid symptoms. Physical examination showed stable vitals and no abnormalities to palpation or vision. Laboratory results obtained showed a dehydroepiandrosterone sulfate level of 26.6 mcg, total metanephrine level of 1289 mg, urine metanephrine level of 819 mg (greater than 2 times the upper limit), and plasma metanephrine level of >5 times the upper limit (although the medication could induce high levels, this would not induce 5 times the limit). The urine norepinephrine level was 37 mcg, and the urine epinephrine level was 11 mcg. For reference, the normal dehydroepiandrosterone sulfate level in a woman aged 50 to 60 years is 26 to 200 mcg, The normal urine metanephrine level for that same age range is 400 mcg, and the plasma metanephrine level for that same age range is 400 to 600 mcg. The norepinephrine level in urine is 10 to 35 mcg, and the urine epinephrine level is 0 to 20 mcg. Computed tomography of the abdomen with adrenal protocol (HU) showed a right adrenal mass shadowing an absolute washout value of 46.5% and a relative washout value of 27%. An absolute washout of < 60% and relative of < 45% indicate benign adrenal masses. Repeat urine studies continued to slow metanephrine levels greater than 2 times the upper limit. Based on these studies, patients were placed on appropriate alpha- and beta-blocker regimen and referred for surgery. Discussion: Pheochromocytoma is usually observed in patients with hypertension. However, patients can have normal pressures or episodes of orthostatic hypotension. With the advent of routine use of imaging, presymptomatic diagnosis of pheochromocytoma occurs in greater than 60% of patients. Conclusion: For patients with a family history or personal history of hypertension, if cardinal symptoms of pheochromocytoma are absent but mood disorders, diaphoresis, and tachycardia during panic attacks occur, this should prompt imaging and workup for pheochromocytoma. Case Report: Identifying Pheochromocytoma in a woman with normotension, history of anxiety disorder, and episodes of orthostatic hypotension. Discussion: A diagnosis of normotension or hypotension does not rule out pheochromocytoma. Conclusion: With high suspicion for pheochromocytoma, prompt workup should be initiated.

Publication Title

Endocrine Practice

Volume

31

Issue

9 Supplement

First Page

S4

Last Page

S5

Comments

AACE Annual Meeting 2025 held 2025-05-15 to 2025-05-17 in Orlando, FL, USA

Link to Full Text

Open Access

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