Endocrine Abstracts

Background: Pheochromocytoma is a rare tumour that arise from chromaffin cells in the adrenal medulla and produces signs and symptoms due to excessive catecholamine secretion from tumour. Presenting symptoms can vary but often they classically present with headaches, sweating and palpitations in the setting of paroxysmal hypertension. Pheochromocytoma crisis results from the sudden release of large quantities of catecholamines and leads to progressive multiple organ dysfunction.

Case presentation: 54 years old gentleman with a history of pheochromocytoma not for surgical resection as high anaesthetics risk, obesity, IHD, CABG, DM type2, toes amputations bilaterally and PVD. Presented with biliary sepsis precipitating pheochromocytoma crisis. The patient admitted to ED with right upper quadrant abdominal pain, jaundice, vomiting and pyrexia. Reported two weeks history of excessive thirst, passing large volume of urine, palpitations and sweating. Vital signs were stable on admission, laboratory Investigations revealed deranged LFTs, raised CRP, WCC and normal blood gases with lactate of 2. Treated as acute cholecystitis with IV antibiotics. On arrival to acute medical unit, became severely unwell, Persistent pyrexia (temperature 40), hypertensive crisis (BP 270/140), sinus tachycardia (HR 140) and hyperglycaemic (BM 33). On assessment he was dehydrated, flushed and sweaty. Repeated ABG showed acidosis, ketones were normal and lactate increased to10. Management was guided by medical registrar and intensive care team, treated with multimodality therapy including excessive IV fluids, alpha-blockers (Phenoxybenzamine and Doxazocin) and variable rate intravenous insulin infusion. Good respond to adequate fluid resuscitation and alpha adrenergic blockade, patient was stabilized and BP regains to normal range. Blood glucose levels improved, vomiting settled and he was able to eat and drink therefore the insulin infusion stopped and restarted on his regular insulin regimen. The Patient improved significantly and discharged home after 5 days.

Conclusion: Pheochromocytoma crisis is a life-threatening medical emergency that necessitates cross-disciplinary expertise and management to ensure the best clinical outcome. If crisis is suspected, an α-blocker treatment with adequate fluid replacement therapy should be initiated as soon as possible. Good history taking and assessment on admission is crucial as if a known diagnosis of pheochromocytoma is overlooked or treatment delayed the consequences could be catastrophic or even fatal; however, prognosis in usually very good if treated appropriately. This case highlights challenges with Pheochromocytoma management when patients are not fit for surgical intervention.