Endocrine Abstracts

Background: SARS-CoV-2 infection is characterized by aspecific symptoms (e.g., fever, cough) and can be complicated by viral pneumonia and many other manifestations can occur. Endocrinological complications have also been described. Pheochromocytomas are rare tumors located in the adrenal medulla, causing symptoms due to catecholamines overproduction and abrupt release. Catecholamines release can be continuous or intermittent and there can be several triggers including stress, physical exercise and some foods. SARS-CoV-2 infections have not been previously described as a precipitator of adrenergic crisis in pheochromocytoma. We report a case of adrenergic crisis caused by SARS-CoV-2 infection in a patient affected by pheochromocytoma.

Case report: A 63-year-old Caucasian male affected by right adrenal pheochromocytoma waiting for surgical removal was admitted to the emergency department (ED) for fainting episode and hypertensive crisis. Patient was known for type 2 diabetes and hypercholesterolemia treated by slow-release metformin 500 mg/day and atorvastatin 40 mg/day and was not vaccinated for SARS-CoV-2. Two months before, he was hospitalized in another center for myocardial infarction with non-obstructive coronary arteries and a chest-abdomen CT scan showed a 1.5 cm right adrenal mass. The 24-h urinary metanephrines were >5000 μg/24h and normetanephrines >2500 μg/24h. Scintigraphy with 250MBq ¹²³I-MIBG showed uptake in the right adrenal gland formation, consistent with pheochromocytoma. Patient was started on alpha-blockers (Doxazosin 2 mg twice/day). Two weeks later, patient was also started on metoprolol 50 mg twice/day. In the ED, BP was 210/108 mmHg with a HR of 105 bpm. A routine nasopharyngeal swab for SARS-COV-2 was performed. After administration of 2 mg of doxazosin and 20 mg of nifedipine, symptoms addressed to catecholamine release disappeared. As the nasopharyngeal swab resulted positive for SARS-COV-2, the patient was transferred to infectious diseases unit. Since mean BP was persistently high, doxazosin was increased to 4 mg twice/day, with beneficial effect on BP and HR. After 10 days, the patient tested negative for SARS-CoV-2 and was discharged, with normal vital parameters and indication to continue the new increased dosage of doxazosin. No other crisis was reported until surgery, that was performed without any complication.

Discussion: Since adrenergic crisis is a life-threatening condition, we suggest close BP monitoring and therapeutic adherence in patients with pheochromocytoma waiting for surgery, living in areas characterized by outbreak of Covid-19 infection. In case of infection, we suggest considering an increase in alpha-blocker dosage in order to prevent crisis.