Endocrine Abstracts

Background: Phaeochromocytoma are rare catecholamine secreting tumours and may present with hypertension, orthostatic hypotension, tachycardia and even cardiogenic shock. These tumours can easily be missed particularly in patients presenting with other disorders. We present a case of a patient with severe community acquired pneumonia who despite overwhelming sepsis was severely hypertensive.

The case: JP was a 33-year-old man who was previously fit and well presented with fever, myalgia and shortness of breath. A chest X-ray demonstrated a right lower lobe pneumonia. He was treated with i.v. co-amoxiclav and clarithromycin and blood cultures grew Streptococci and Staphylococci.

However, despite antibiotic treatment his CRP was 418 and his temperature remained persistently elevated four days after admission. Paradoxically he remained hypertensive with sytstolic blood pressures of over 200 mmHg despite a marked systemic inflammatory response.

Due to poor response to antibiotics, a CT scan of chest and abdomen was performed. This demonstrated a large right sided pleural effusion with consolidation of the lung above. A CT guided chest drain was placed to drain the effusion which turned out to be an empyema. Furthermore, an incidental right sided 4.2 cm adrenal mass was noted.

In view of the raised blood pressure, a phaeochromocytoma was suspected and investigations carried out after the acute phase showed a raised 24 h urinary normetadrenaline levels of 19 and 12 μmol/24 h (0–7). Urine free cortisol excretion marginally elevated at 644 nmol/24 h. He was commenced on Phenoxybenzamine 10 mg tds.

Three months after discharge for the pneumonia, he had an MIBG scan and elective laparoscopic adrenalectomy. Urine normetadrenaline excretion and BP normalized following the surgery.

Discussion: Severe sepsis may unmask underlying phaeochromocytoma and should be suspected in patients with severe hypertension during profound sepsis.