Thyrotoxic and pheochromocytoma multisystem crisis: a case report

Abstract

BackgroundThyrotoxic crisis and pheochromocytoma multisystem crisis are rare, life-threatening, emergency endocrine diseases with various clinical manifestations. Here we report a case of a patient who simultaneously developed thyrotoxic crisis and pheochromocytoma multisystem crisis and required intensive cardiovascular management.Case presentationA 60-year-old Asian man experienced nausea and vomiting, and subsequently developed dyspnea and cold sweats while farming. His serum free thyroxine, free triiodothyronine, and thyrotropin receptor antibody levels were elevated at 2.9 ng/dL, 7.2 pg/dL, and 4.7 IU/L, respectively. Serum thyrotropin levels were suppressed at less than 0.01 μIU/mL. Thyroid echography demonstrated no thyroid swelling (23 × 43 mm).A whole body computed tomography was performed for systemic evaluation. This revealed exophthalmos and a mass of size 57 × 64 mm in the anterior pararenal space. Based on these findings, we made an initial diagnosis of thyrotoxic crisis secondary to exacerbation of Grave’s hyperthyroidism. Treatment was begun with an iodine agent at a dose of 36 mg/day, thiamazole at a dose of 30 mg/day, and hydrocortisone at a dose of 300 mg daily for 3 consecutive days. To control tachycardia, continuous intravenously administered propranolol and diltiazem infusions were given. At the same time, small doses of doxazosin and carvedilol were used for both alpha and beta adrenergic blockade. On hospital day 5, his blood pressure and serum catecholamine concentrations (adrenalin 42,365 pg/mL, dopamine 6409 pg/mL, noradrenalin 72,212 pg/mL) were still high despite higher beta blocker and calcium channel blocker doses. These findings contributed to the diagnosis of pheochromocytoma multisystem crisis with simultaneous thyrotoxic crisis. We increased the doses of doxazosin and carvedilol, which stabilized his hemodynamic status. On hospital day 16, metaiodobenzylguanidine scintigraphy showed high accumulation in the right adrenal gland tumor. After retroperitoneal laparoscopic adrenalectomy on hospital day 33, his condition stabilized. He was discharged on hospital day 58.ConclusionsSince he required more intensive cardiovascular management for thyrotoxic crisis, beta blockade was increased under intensive care unit monitoring even though initial alpha blockade is recommended in pheochromocytoma. When these crises occur simultaneously, cardiovascular management can be very challenging.

Cardiovascular Manifestations and Complications of Pheochromocytomas and Paragangliomas

“…Worth mentioning is that a multi-endocrine crisis may occur as thyrotoxicosis crisis together with pheochromocytoma multisystem crises have been reported [120] and this requires intensive cardiovascular management. In such cases, alpha-and beta-blockers may be started simultaneously.…”

Pheochromocytoma: A Troublesome Tumor

“…For example, both diseases can cause high blood pressure, leading to misdiagnosis if the blood pressure is solely relied upon. Other common features include tachycardia, palpitations, sweating, flushing, heat intolerance, anxiety, panic attacks, weight loss, and fatigue; thereby, making it difficult to pinpoint the underlying condition [9][10][11].…”

Manejo emergencial da crise tireotóxica: uma revisão integrativa da literatura

“…Frequentemente a tempestade tireoide é desencadeada por alguma causa específica que hiperestimula a secreção de hormônios tireoidianos, liberam-nos de proteínas carreadoras e/ou aumentam a sensibilidade dos receptores desses hormônios (IDROSE, 2015). O principal fator precipitante da CT é infecção, entretanto, pode-se incluir como outras causas: cetoacidose diabética (IINO; AKATSUKA; YAMAMOTO, 2022); hipoglicemia; coma hiperosmolar; embolia pulmonar; overdose de hormônios tireoidianos (LI et al, 2021); hipertireoidismo prolongado não tratado (VISWANATH; MENAPACE; HEADLEY, 2017); retirada de Brazilian Journal of Health Review, Curitiba, v. 6, n. 4, p.18913-18927, jul/aug., 2023 medicações antitireoidianas; ingestão de contraste iodado (SUZUKI et al, 2017); uso de metanfetamina (VISWANATH; MENAPACE; HEADLEY, 2017); uso de amiodarona (TENÓRIO et al, 2023;ZHU et al, 2016); acidente vascular; cirurgia; estresse; parto; doenças trofoblásticas gestacionais (SALEEM et al, 2021); gestação, incluindo a gestação ectópica (CARREIRA et al, 2022); eclâmpsia; trauma; infarto do miocárdio; e terapia com iodo radioativo (IDROSE, 2015).…”