Catecholaminergic Crisis After a Bleeding Complication of COVID-19 Infection: A Case Report

Rebollo-Roman, Angel; Alhambra-Expósito, María Rosa; Herrera‐Martínez, Yiraldine; Leiva-Cepas, Fernando; Alzas, Carlos; Munoz-Jimenez, Concepcion; Ortega‐Salas, Rosa; Molina-Puertas, María J.; Gálvez-Moreno, María Ángeles; Herrera‐Martínez, Aura D.

doi:10.3389/fendo.2021.693004

Cited by 6 publications

(11 citation statements)

References 19 publications

(34 reference statements)

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“…Importantly, our patient was completely normotensive, and apart from sweating, not all the other symptoms would certainly arouse suspicion of PCC. While clinicians often put too much emphasis on the presence of hypertension, the absence of a positive history of hypertension in our patient might have contributed to the lack of suspicion of a catecholamine-producing tumor, hindering the timely treatment of this potentially life-threatening tumor ( 11 , 12 ).…”

Section: Discussionmentioning

confidence: 93%

Case report: Incidentally discovered case of pheochromocytoma as a cause of long COVID-19 syndrome

et al. 2022

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Pheochromocytomas (PCCs) are rare but potentially lethal tumors that arise from the adrenal medulla. The clinical suspicion and diagnosis of PCC can be challenging due to the non-specific nature of signs and symptoms. In many patients, infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) could lead to long-term symptoms including fatigue, headaches, and cognitive dysfunction. Here, we present the case of a patient incidentally diagnosed with an adrenal mass that proved to be a PCC after imaging was performed due to persisting complaints after coronavirus disease 2019 (COVID-19) infection. A 37-year-old male patient was referred to our center because of a right-sided inhomogeneous adrenal mass, incidentally found during a computed tomographic scan of the thorax performed due to cough and dyspnea that persisted after COVID-19 infection. Other complaints that were present prior to COVID-19 infection included profuse sweating, dizziness, exhaustion with chronic fatigue, and concentration difficulties. The patient had no history of hypertension, his blood pressure was normal, and the 24-h ambulatory blood pressure monitoring confirmed normotension but with the absence of nocturnal dipping. Plasma normetanephrine was 5.7-fold above the upper limit (UL) of reference intervals (738 pg/ml, UL = 129 pg/ml), whereas plasma metanephrine and methoxytyramine were normal at 30 pg/ml (UL = 84 pg/ml) and <4 pg/ml (UL = 16 pg/ml), respectively. Preoperative preparation with phenoxybenzamine was initiated, and a 4-cm tumor was surgically resected. Profuse sweating as well as dizziness was resolved after adrenalectomy pointing toward PCC and not COVID-19-associated patient concerns. Altogether, this case illustrates the difficulties in recognizing the possibility of PCC due to the non-specific nature of signs and symptoms of the tumor, which in this case did not include hypertension and coincided with some of the symptoms of long COVID-19.

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Section: Discussionmentioning

confidence: 93%

Case report: Incidentally discovered case of pheochromocytoma as a cause of long COVID-19 syndrome

et al. 2022

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“…Adrenal hemorrhage has been exceptionally described in relationship with medulla; a first case of pheochromocytoma-related hemorrhage in a 62-year-old male admitted for coronavirus-associated pneumonia was the initial sign that led to the detection of the adrenal tumor [87].…”

Section:  Discussionmentioning

confidence: 99%

COVID-19 infection: from stress-related cortisol levels to adrenal glands infarction

Popescu

Terzea²,

Cârșote³

et al. 2022

Rom J Morphol Embryol

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Cortisol is a key element in acute stress including a severe infection. However, in coronavirus-associated disease, 20% of subjects experience hypocortisolemia due to direct or immune damage of pituitary and adrenal glands. One extreme form of adrenal insufficiency is found in 2/3 of cases with viral and post-viral adrenal infarction (AI) (with/without adrenal hemorrhage) that is mostly associated with a severe coronavirus disease 2019 (COVID-19) infection; it requires prompt glucocorticoid intervention. Some reports are incidental findings at computed tomography (CT)/magnetic resonance imaging (MRI) scans for non-adrenal complications like pulmonary spreading and others are seen on post-mortem analysis. This is a review of PubMed-accessible, English papers focusing on AI in addition to the infection, between March 1, 2020 and November 1, 2021. Exclusion criteria were acute adrenal insufficiency without the histopathological (HP) and/or imaging report of adrenal enlargement, necrosis, etc., respective adrenal failure due to pituitary causes, or non-COVID-19-related adrenal events. We identified a total of 84 patients (different levels of statistical evidence), as follows: a retrospective study on 51 individuals, two post-mortem studies comprising nine, respectively 12 patients, a case series of five subjects, seven single-case reports. HP aspects include necrosis associated with ischemia, cortical lipid degeneration (+/-focal adrenalitis), and infarcts at the level of adrenal cortex, blood clot into vessels, acute fibrinoid necrosis in arterioles and capsules, as well as subendothelial vacuolization. Collateral potential contributors to adrenal damage are thrombotic events, coagulation anomalies, antiphospholipid syndrome, endothelial dysfunction, severe COVID-19 infection with multiorgan failure, etc. Clinical picture is variable from acute primary adrenal insufficiency to asymptomatic or mild evolution, even a retrospective diagnostic; it may be a part of long COVID-19 syndrome; glucocorticoid therapy for non-adrenal considerations might mask cortisol deficient status due to AI/hemorrhage. Despite its rarity, the COVID-19-associated AI/hemorrhage represents a challenging new chapter, a condition that is essential to be recognized due to its gravity since prompt intervention with glucocorticoid replacement is lifesaving.

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“…We also reviewed all the articles published from 2005 to 2022 in PubMed, dedicated to adrenal bleeding with known results of urinary or plasma catecholamines or metanephrines (8,10,12,14,16,17,24,. The analysis showed that catecholamines or metanephrines (plasma or urine) were elevated in 38.9% of patients with adrenal bleeding without pheochromocytoma.…”

Section: Discussionmentioning

confidence: 99%

“…Phenoxybenzamine and doxazosin are the most commonly used. The main differences between those two drugs concern selectivity (8,10,12,14,16,17,24,.…”

Section: Discussionmentioning

confidence: 99%

“…Although most cases of hemorrhage within a pheochromocytoma are spontaneous, sometimes episodes of bleeding could be precipitated by preceding anticoagulant therapy (5), trauma (6) or thrombolysis (7). Lately, the first case of hemorrhage in a pheochromocytoma in the course of SARS-CoV-2 infection was described (8). Moreover, adrenal hematoma could sometimes mimic neoplasm of the adrenal gland (1,9,10).…”

Section: Introductionmentioning

confidence: 99%

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Adrenal bleeding due to pheochromocytoma - A call for algorithm

et al. 2022

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BackgroundAdrenal hemorrhage is a rare, usually life-threating complication. The most common neoplasm resulting in spontaneous adrenal bleeding is pheochromocytoma and it accounts for nearly 50% of cases. Currently, the recommendations for the diagnosis and management of patients with adrenal bleeding due to pheochromocytoma are unavailable.Materials and methodsWe performed a database search for all pheochromocytoma patients, diagnosed and treated from 2005 to 2021 in tertiary endocrinology center. 206 patients were identified, 183 with complete data were included in the analysis. We investigated clinicopathological characteristics, treatment and outcomes of hemorrhagic pheochromocytoma cases and characterize our approach to perioperative diagnosis and medical management. Finally our experiences and data from previously published articles concerning adrenal hemorrhage were analyzed to propose a diagnostic and therapeutic algorithm for hemorrhagic pheochromocytomas.ResultsIn the whole group, seven patients (4 men and 3 women) with adrenal bleeding were found, (3.8%). Median patient’s age was 49 years (range: 36-78 years). The most common manifestation of adrenal bleeding was acute abdominal pain (5/7). Two patients developed shock. Hormonal assessment was performed in five patients, based on 24-hour urinary fractionated metanephrines with urinary 3-methoxytyramine. Normetanephrine was elevated in all patients, metanephrine and 3-methoxytyramine - in four cases (4/5). Most patients (6/7) had symptoms suggesting pheochromocytoma before hemorrhage – most commonly paroxysmal hypertension (4/7). One patient died, before the diagnosis of adrenal bleeding was made. Diagnostic imaging performed in six out of seven patients revealed adrenal tumor, with median largest diameter equal to 7.4 cm (range: 5-11 cm). Five patients had elective surgery, in one case an urgent surgery was performed. In all cases the diagnosis of pheochromocytoma was confirmed in postoperative histopathology or in autopsy. The perioperative survival rate was 85.7%.ConclusionsDiagnosis of pheochromocytoma should be always considered in patients with adrenal bleeding, especially with accompanying abdominal pain, hemodynamic shock and previous history of pheochromocytoma-associated symptoms. Lack of proper diagnosis of pheochromocytoma before surgery is associated with an additional perioperative risk. To improve the decision making in this life-threatening clinical situation, based on our results and literature data, we proposed a diagnostic and treatment algorithm.

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Catecholaminergic Crisis After a Bleeding Complication of COVID-19 Infection: A Case Report

Cited by 6 publications

References 19 publications

Case report: Incidentally discovered case of pheochromocytoma as a cause of long COVID-19 syndrome

Case report: Incidentally discovered case of pheochromocytoma as a cause of long COVID-19 syndrome

COVID-19 infection: from stress-related cortisol levels to adrenal glands infarction

Adrenal bleeding due to pheochromocytoma - A call for algorithm

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