Periodic fluctuation of blood pressure and its management in a patient with pheochromocytoma. Case report and review of the literature.

Oishi, Seiichi; Sato, Masato; Ohno, Miho; Umeda, Teruhisa; Satô, Tatsuo

doi:10.1536/ihj.29.389

Cited by 20 publications

(20 citation statements)

References 12 publications

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“…11,12 While not true in our case, pure epinephrine-secreting tumors can present with episodic hypotension due to stimulation of b2receptors resulting in vasodilatation. Hypertension is not always present, and patients may present with hypotension due to cardiogenic shock or hypovolemic shock.…”

Section: Discussionmentioning

confidence: 58%

Rapid Onset and Resolution of Cardiogenic Shock in a Patient With Pheochromocytoma

Shih

Williams

Merlino

et al. 2009

Congestive Heart Failure

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A pheochromocytoma is a rare catecholamine-secreting tumor that can be familial or arise sporadically. Its typical presenting features include symptoms of headache, palpitations, and diaphoresis occurring in paroxysms. The classic presenting sign is episodic hypertension, although only in 59% of cases, have evidence of hypertension at diagnosis. 1 There have been a few case reports of patients with pheochromocytoma presenting with cardiogenic shock 2-10 but none with both cardiogenic shock and ventricular tachycardia. Additionally, we are not aware of any case reports of such a rapid decline and then improvement in ejection fraction (EF) as demonstrated in this case. We report the unusual presentation of a patient who developed cardiogenic shock within seconds during the course of a single transthoracic echocardiogram (TTE) only to recover minutes later without intervention. Case ReportA 69-year-old man with type II diabetes mellitus presented with a complaint of a single syncopal episode to an outside institution. The patient was found to have multiple ventricular ectopic beats and frequent runs of nonsustained ventricular tachycardia. The patient was a past smoker but had no personal history of cardiovascular disease or other additional significant medical history. Family history was significant for hypertension and diabetes. The patient was taking metformin and glipizide for his type II diabetes mellitus. The physical examination was significant for orthostasis and an S4 gallop. The remainder of the physical examination was unremarkable. Initial laboratory results demonstrated mildly elevated troponin levels at 0.55 ng ⁄ mL and acute renal failure with a serum creatinine of 1.9 mg ⁄ dL. The patient's hemoglobin concentration was 18.5 g ⁄ dL. There were no other significant laboratory abnormalities. The patient was subsequently transferred to our center for urgent cardiac catheterization for suspected acute coronary syndrome. On transfer, the patient's heart rate was elevated and his blood pressure (BP) was noted to be labile: alternating between severe hypotension and hypertension (Table I).On arrival, an initial electrocardiogram was obtained which showed ventricular ectopics and left ventricular hypertrophy (Figure 1). On telemetry, the patient continued to have multiple episodes of nonsustained ventricular tachycardia (Figure 2). An urgent TTE was performed to assess for regional wall motion abnormalities and to a pericardial effusion that might explain the reason for shock. The initial EF based on the subcostal, short-axis, and parasternal long-axis views was 50% to 55% (Figure 3A and Figure 3B). During the study the EF unexpectedly declined to 5% to 10% ( Figure 3C and Figure 3D) at which time the patient's BP dropped to 68 ⁄ 34 mm Hg and the patient became unresponsive. Fluid resuscitation was initiated and the patient was taken emergently to the cardiac catheterization laboratory.After placement of a right femoral artery sheath, the patient's intraarterial BP was found to be 62⁄ 38 mm Hg. A second left ...

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Section: Discussionmentioning

confidence: 58%

Rapid Onset and Resolution of Cardiogenic Shock in a Patient With Pheochromocytoma

Shih

Williams

Merlino

et al. 2009

Congestive Heart Failure

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“…In contrast, Oishi and associates 5 documented fluctuation in BP that was associated with cyclic changes in NE secretion. In their review of 16 patients, the majority had a single right‐sided adrenal tumor (12/16).…”

Section: Discussionmentioning

confidence: 85%

“…There is accumulating evidence that pheochromocytoma, apart from the classic hypertensive cycles, can also present with rapidly cycling paroxysms of hypertension alternating with hypotension 3–5 . Kobal and associates 3 reviewed 7 cases of this unusual form of pheochromocytoma and proposed that the BP fluctuations are associated with tumors that predominantly secrete EPI.…”

Section: Discussionmentioning

confidence: 99%

Cyclic Rapid Fluctuation of Hypertension and Hypotension in Pheochromocytoma

Ionescu¹,

Sakharova

Harwood³

et al. 2008

J of Clinical Hypertension

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Pheochromocytomas are rare catecholamineproducing neuroendocrine tumors arising from the chromaffin cells of the adrenal medulla (80%-85%) or extra-adrenal paraganglia (15%-20%). The secretory profiles of these tumors vary but predominately secrete norepinephrine (NE) with lesser amounts of epinephrine (EPI). The prevalence of pheochromocytoma in the outpatient hypertensive population is reported to be somewhere between 0.1% and 0.9%; about 25% are discovered incidentally during imaging studies for unrelated disorders. 1The clinical presentation of pheochromocytomas can vary greatly but is typically described as spells with the classic triad of tachycardia, headaches, and diaphoresis occurring in at least 25% of cases. Severe hypertension is usually present during the attacks. Other symptoms can include pallor; tremulousness; orthostatic hypotension, especially in the morning (that may reflect a low plasma volume); visual blurring; papilledema; weight loss; polyuria; and polydipsia. Several medications, including opiates, metoclopramide, tricyclic antidepressants, and anesthesia can induce pheochromocytoma-related hypertension. Hypertension and ⁄ or hypertensive spikes are the result of catecholamines on the cardiovascular system probably coupled with enhanced sympathetic nervous system activity.The diagnosis is often not made for many years because of the fleeting episodes and nonspecific symptoms. It is usually entertained when there is a history of spells with sweating and palpitations, resistant hypertension, family history of pheochromocytoma, or incidentally discovered adrenal mass. There is no consensus on the best chemical test for diagnosing pheochromocytoma, but high sensitivities are achieved by measuring fractionated metanephrines and catecholamines in a 24-hour urine collection (97%) or fractionated plasma free metanephrines (99%). Tumor localization with computed tomography or magnetic resonance imaging should normally take place after biochemical confirmation of the pheochromocytoma.Treatment with a-blockers, usually combined with a b-blocker, prior to tumor removal decreases mortality associated with surgery.2 There is no consensus on the preferred agent, but competitive (doxazosin or prazosin) or noncompetitive and longer-acting (phenoxybenzamine) a-blockers are usually used. Alternatives are the mixed a ⁄ b-blocker labetalol, dihydropyridine calcium channel blockers, or metirosine. 1 We report on a rare presentation of pheochromocytoma with rapid alternating cycles of hypertension and hypotension successfully treated with fluid expansion and metirosine prior to tumor removal. CASE REPORTA 47-year-old woman presented for an EPS for evaluation of palpitations. She had hypertension

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“…Other signs and symptoms that may occur include orthostatic hypotension, visual blurring, papilloedema, polyuria, polydipsia, hyperglycaemia, psychiatric disorders, dilated cardiomyopathy and rarely erythrocytosis. Patients with tumours that secrete only adrenaline can present with episodic hypotension and rarely with rapid cyclic fluctuation of blood pressure 8, 9…”

Section: Discussionmentioning

confidence: 99%

Resolution of insulin treated diabetes and hypertension following resection of an asymptomatic phaeochromocytoma

2005

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The clinical and biochemical manifestations which occur in diseases associated with hormone excess, such as phaeochromocytoma, usually resolve when the hormone levels are normalised. This patient with long-standing diabetes mellitus and hypertension was incidentally found to have a completely asymptomatic phaeochromocytoma. Both hypertension and diabetes completely resolved on surgical extirpation of the tumour.We present the case of a 53-year-old male patient with diabetes and hypertension, with a blood pressure of 150/80mmHg and an HbA1c of 9% on three antihypertensive agents and insulin therapy. He was found to have a slightly raised alanine aminotransferase of 81IU/L on routine tests. An abdominal ultrasound incidentally revealed a large right adrenal mass. He had no symptoms suggestive of a phaeochromocytoma. His urinary noradrenaline excretion was raised at 4636nmol (70-580nmol/24hours). An MRI scan confirmed the right adrenal mass. He underwent an adrenalectomy and the histology confirmed a phaeochromocytoma. Subsequently, his insulin requirements fell and all therapy for diabetes and hypertension was withdrawn.While diabetes and hypertension are very common, an asymptomatic phaeochromocytoma may rarely be responsible, and its removal curative, for both conditions.

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Periodic fluctuation of blood pressure and its management in a patient with pheochromocytoma. Case report and review of the literature.

Cited by 20 publications

References 12 publications

Rapid Onset and Resolution of Cardiogenic Shock in a Patient With Pheochromocytoma

Rapid Onset and Resolution of Cardiogenic Shock in a Patient With Pheochromocytoma

Cyclic Rapid Fluctuation of Hypertension and Hypotension in Pheochromocytoma

Resolution of insulin treated diabetes and hypertension following resection of an asymptomatic phaeochromocytoma

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