Endocrine Abstracts

The classic episodic triad of headache, sweating and palpitations facilitates the diagnosis of phaeochromocytoma. The absence of these symptoms can lead to misdiagnosis in patients with uncommon symptoms attributable to phaeochromocytoma. We present such a case.

Case report: A 64 year old man was referred to endocrinology having been coincidentally found to have a right adrenal mass with features of a phaeochromocytoma. He was asymptomatic and engaged in regular formal exercise. Hypertension diagnosed seven years earlier was treated with bisoprolol, amlodipine and losartan. Five years earlier multiple cerebral infarcts were found on presentation with sequential neurological deficits. Our biochemical and imaging investigations confirmed a diagnosis of solitary phaeochromocytoma.24 hour blood pressure monitoring revealed extreme lability exceeding the normal limits of cerebral autoregulation of blood flow.24 hour electrocardiography revealed episodes of asymptomatic trigeminy and ventricular tachycardia. Alpha blockade with doxazosin improvedblood pressure lability with resolution of arrhythmias prior to laparoscopic adrenalectomy. At the time of diagnosis of multiple cerebral infarcts the stroke team initially found mild weakness and reduced sensation in the right arm. A diagnosis of cervical myelopathy was supported by finding degenerative changes on x-ray. One week later he developed visual disturbance and was found to have a left homonymous hemianopia. CT brain confirmed infarction in areas perfused by the middle cerebral artery. MRA was normal but MRI confirmed right parietal, occipital and cerebellar infarcts. These findings led to extensive investigations with involvement of cardiologists, haematologists and neurologists. Such investigations excluded vasculitis, thrombophilia, diabetes, HIV and sarcoid.4-D cerebral CT angiography, transthoracic and transoesophageal echocardiography were normal. Seven day electrocardiography detected asymptomatic episodes of atrial fibrillation and complex ventricular tachycardia. Repeat MRI confirmed a new large pontine infarct. Throughout the investigations blood pressure ranged from 108/61 mmHg to 130/80 mmHg. He was discharged to primary care following anti-coagulation with warfarin with a putative diagnosis of multiple cerebral infarcts secondary to embolic events.

Discussion: This case confirms the presentation vagaries of phaeochromocytoma, it remains “the great mimic”.Colleagues who managed him previously confirmed a failure to “think of it”, particularly in view of the apparently normal blood pressure levels. It behoves endocrinologists to highlight the protean manifestations of phaeochromocytoma, particularly in patients with unexplained cerebrovascular events and arrhythmias.