Associates' Presentations
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Pheochromocytoma - An unusual presentation as nausea in the shower.
Grace Devadas, M.D., (Associate), John L. Olson, M.D., Frank Guzowski, M.D. Marshfield Clinic/St. Joseph' Hospital, Marshfield, Wisconsin.
A 32 year old white female presented with a 6 month history of episodic morning nausea and severe retching with posterior cervical pain for a period of 5 minutes while in the shower. The rest of the day she remained symptom free. She was under treatment for panic attacks with alprazolam (for her current symptoms). She was otherwise in good health except for a history of nephrolithiasis in 1994.
On examination her blood pressure was 120/72 and pulse 70 bpm. The remainder of her physical exam was normal. Evaluations included an ultrasound of the abdomen which revealed a large left adrenal tumor which was confirmed by CT scan. Plasma norepinephrine was 1117 picograms/ml (70-750) epinephrine 98 picograms/ml (0-110) and dopamine 41 picograms/ml (<30), correlating with 24 hour urine VMA results of 52.4 mg/24 hr (0-7.2).
She was evaluated for MEN type II a & b, neurofibromatosis and Von Hippel Lindau Syndrome. During the hospitalization she manifested intermittent episodes of hypertension. Patient underwent left adrenalectomy after standard pre-operative preparation. Histopathology confirmed the diagnosis of pheochromocytoma. Patient did not experience recurrent symptoms post-operatively.
Pheochromocytoma are often sought, but rarely found, with an incidence of less than 0.1% of hypertensive patients. Pheochromocytoma presents in 60% of the patients as sustained hypertension and in 56% of patients with paroxysmal symptoms; the most common being headache (80%). Paroxysms are often triggered by any movement that shifts the abdominal viscera. Also, unlike the normal adrenal medulla, a pheochromocytoma is not innervated, and hence catecholamine release is not initiated by neural impulses. Changes in blood flow, however, can initiate catecholamine release. In our patient hot showers resulting in peripheral vasodilation and decreased splanchnic blood flow may have been the cause for tumor stimulation and her symptoms.
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