Endocrine Abstracts

A 63 year old man was admitted with headache, nausea, vomiting and BP of 247/155 mmHg. He had a 4 month history of headache. Past medical history of depression, back pain and 40 pack year smoking history. There was no history of chest pain, palpitation or neurological disturbance. ECG: sinus rhythm, Rate 110, LVH. Cholesterol 6.1 mmol/l. Creatinine 118umol/l. CT head unremarkable. He was commenced on amlodipine. Tramadol and pregabalin were stopped due to possible serotonin syndrome. Sertraline continued in view of ongoing depression. He was alpha-blocked with doxazosin and subsequently beta-blocked with propranolol. Due to severe and labile blood pressure, inpatient MRI adrenals and MRA renal arteries performed. This showed proximal stenosis/thrombosis of the left renal artery with patent accessory artery to left superior pole. Atheromatous disease of the aorta and some atrophy of the left kidney. Normal appearance of adrenal glands. He was discharged on day 7 after stabilisation of blood pressure. Plasma metanephrines (taken within 24 hours of admission): Normetanephrine 1779 pmol/l (0- 1180), metanephrine 282pmol/l (0-510). Aldosterone 764pmol/l and renin 17.1nmol/l/h. In renal artery stenosis, excess renin is secreted by ischaemic kidney. Repeat OPD plasma metanephrines after stopping sertraline for 2 weeks within normal range (normetanephrine 859 pmol/l). Vascular MDT: For medical management with atorvastatin and clopidogrel. Average BP 123/79 mmHg on outpatient 48 hour monitoring. Renal function stable. Follow up with renal physicians for medical optimisation.

Conclusions: 2014 Endocrine society guidelines recommend CT as initial imaging for suspected pheochromocytoma. Renovascular hypertension is a common cause of secondary hypertension. In patients presenting with severe hypertensive crisis, inpatient MRA renal arteries/MRI adrenals may be a more appropriate form of imaging. This patient had significant risk factors for atherosclerotic disease. Polypharmacy may have contributed to patient’s initial presentation.