Endocrine Abstracts

A 45-year-old female patient with diagnosis of hypertension was admitted to Acibadem University Hospital for colonoscopy due to perianal abscess and rectovaginal fistula. She had been diagnosed with hypertension for 7 years and had been using 3 different classes of antihypertensive drugs. Intermittent hypertensive attacks and hospitalization for myocarditis history was documented. During anesthesia induction for colonoscopy her condition acutely worsened and she became hemodynamically unstable. She developed acute respiratory distress and was transferred to the intensive care unit. On physical examination, she was conscious, tachypneic, hypoxic and had wheezing under 15 lt/min oxygen support. Vital signs were; heart rate:150 bpm, respiratory rate: 32/minute, blood pressure:140/70 mmHg. Bilateral diffuse widespread infiltrates were seen in the chest radiography. Echocardiography demonstrated 30% ejection fraction. Blood gasses analysis revealed severe metabolic acidosis and hypoxia. She was put on non-invasive mechanical ventilation support. Arterial hypoxia persisted hence she was intubated. Due to insufficient response to diuretic therapy and multiorgan dysfunction syndrome she was put on continuous veno-venous hemodiafiltration (CVVHDF) and arteriovenous extracorporeal membrane oxygenation (ECMO) respectively. After 6 days of ECMO support, ejection fraction increased to 40%. Considering her clinical findings being suggestive of pheochromocytoma, radiologic and laboratory tests were ordered. Abdominal computed tomography (CT) revealed an 86x76 mm sized left adrenal mass. Levels of plasma metanephrines (179.5 pg/ml) (reference <90 pg/ml) and plasma normetanephrine (>4800 pg/ml) (reference <200 pg/ml) were determined. Gallium-68 DOTATATE PET/CT imaging revealed increased uptake on the mass (SUVmax: 43). Preoperative antihypertensive preparation was done with doxazosin and metoprolol. Then she underwent left adrenalectomy, splenectomy, left nephrectomy and cholecystectomy. Postoperative pathology confirmed diagnosis of pheochromocytoma. During weaning from mechanical ventilation, it was discovered that she developed polyneuropathy. EMG results were compatible with critical illness neuro-myopathy. Intravenous immunoglobulin (IVIG) therapy for 5 days was given. Plasma metanephrine levels returned to normal level post-operative 2 weeks later and she didn’t need any antihypertensive drugs. The patient was subsequently discharged, and has remained stable 1st year follow-up.