Endocrine Abstracts

Phaeochromocytoma is rare and can be challenging to diagnose. The classic triad of paroxysmal headache, palpitations and pallor is not seen in most cases and the presentation can be more unusual. We describe a case of chronic nocturnal headaches caused by Phaeochromocytoma. A 58-year-old man with a PMHx of Essential Hypertension and Diabetes Mellitus Type 2 presented overnight to the Emergency Department with a sudden and severe “thunderclap headache”. The patient described a history of nocturnal headaches over several years and stated that his symptoms had been worsening, increasing in frequency and severity, over the few months leading up to presentation. He had been investigated as an OP and had a normal MRI brain. He had recently been started on Ramipril and his DM2 was diet controlled. Palpitations and pallor had not been described but patient and wife recounted a “funny turn” episode years before: he had a minor bang to abdomen, felt very unwell, collapsed before having a seizure. Initially, SAH was the concern but was ruled out by CT brain and lumbar puncture. Neurology review was sought and a primary headache disorder, Hypnic Headache, was suspected but features were atypical. He was found to be hypertensive, especially overnight, and ECG revealed an LVH pattern. HS-Troponin was raised but he had never had chest pain. He was investigated for secondary hypertension and Phaeochromocytoma was confirmed biochemically and radiologically: plasma metanephrines revealed normetanephrine >25000 pmol/l, metanephrine 23300 pmol/l, 3-methoxytyramine 1320 pmol/l with CT and MIBG showing a large left Phaeochromocytoma with possible metastasis to liver and pelvis. The patient was quickly medical managed with alpha and then beta blockade before he underwent a successful adrenalectomy. His symptoms have now resolved and he remains under MDT F/U and is planned to have MIBG therapy.