Rapid cyclic fluctuations of blood pressure associated with an adrenal pheochromocytoma.

Abstract

SUMMARY We present a patient with an adrenal pheochromocytoma with an unusual pattern of periodic alternating hypertension and hypotension. Alpha-adrenergic blockade alone failed to affect this pattern, which was abolished only after fluid repletion. The efficacy of volume expansion in ultimately correcting the wide fluctuations of blood pressure implicates a possible reflex neurogenic mechanism for the cyclic changes in blood pressure attributable to intravascular volume contraction. (Hypertension 6: 281-284, 1984) KEY WORDS • adrenal• pheochromocytoma adrenergic blockade • catecholamines • hypertension E PISODIC rises in blood pressure in patients harboring pheochromocytoma are well known. 1However, rapidly occurring cyclical hypertension alternating with hypotension in such patients has rarely been documented.2 3 In one report, a catecholamine-secreting glomus jugulare tumor was associated with such a response. 3 We report here a similar response in a patient with an adrenal pheochromocytoma. Alpha-adrenergic blockade with phentolamine alone did not control the blood pressure fluctuations, which finally abated only when volume replacement was instituted. Case Report HistoryThis 67-year-old man had diabetes mellitus for 15 years. Two years earlier he had been admitted to a hospital for evaluation of precordial pain, episodes of sweating, weakness, and dyspnea associated with marked bradycardia. He was felt to have "sick sinus syndrome" and a permanent pacemaker was placed. Even after the placement of the pacemaker he contin- ued to have symptoms, which were attributed to suboptimal functioning of the pacemaker. He was taking 28 units of Lente insulin for the diabetes mellitus but had not experienced hypoglycemia. During the 6 months preceding the first admission to our hospital he had short attacks of "rapid heart beat" and diaphoresis. A malfunction of the pacemaker was suspected, but when the demand rate was decreased from 72 to 60 bpm, symptoms persisted. Hypoglycemia was also considered, but adjusting his insulin regimen did not change the symptoms. Office blood pressure measurements had always been less than 140/90 mm Hg. On the day of his admission to the local hospital he had several bouts of vomiting associated with headache, pain over his left eye, profuse sweating, palpitation, and left infracostal pain. A diagnosis of acute myocardial infarction was considered. ExaminationThe blood pressure on admission to the coronary care unit was 230/130 mm Hg, but fluctuated to as low as 120/60. Blood glucose concentration was 428 mg/dl. The patient was treated for a short time with hydrochlorothiazide, propranolol, and apresoline for the hypertension, but the blood pressure continued to fluctuate and he was transferred to the Indiana University Medical Center. On admission he was found to be diaphoretic, pale, with cool and clammy skin and was nauseated. At first it was thought that he became hypotensive when sitting, but hypotensive episodes occurred even when supine. maker unit was in place over his right ...

Cyclic Rapid Fluctuation of Hypertension and Hypotension in Pheochromocytoma

“…The literature has conflicting data about the utility of fluid resuscitation and a-blockade in these cases. 3,6,7 Previous reports have shown improvement and stabilization in BP following phentolamine administration, 3 while others have not. 6 Our patient was initially treated with normal saline, but there is no universal acceptance of the benefits of this approach.…”

“…Other mechanisms proposed to explain the development of rapidly fluctuating BP were ischemic response of the central nervous system and intravascular volume contraction. 6 BP oscillations are generally followed by hypotension; this has been described after experimental infusion of catecholamines as well as with adrenergic shock. 7 Massive release of catecholamines could result in decreased receptor activity.…”

Cyclic fluctuation of blood pressure in neonatal neuroblastoma

“…A reflex mechanism involving chemoreceptors or baroreceptors induced by hypovolemia and an ischemic response of the central nervous system are other proposed causes. 9,11 The correction of hypovolemia by infusion and the α-adrenergic blockade were important for treating the cyclic blood pressure fluctuations in pheochromocytoma. [9][10][11] Catecholamine excess can induce several other complications, such as hypertension, 4,7 seizure, 12 heart failure, 7 cardiomegaly, and symptoms mimicking early-onset sepsis 13 in patients with neuroblastoma.…”

“…9,11 The correction of hypovolemia by infusion and the α-adrenergic blockade were important for treating the cyclic blood pressure fluctuations in pheochromocytoma. [9][10][11] Catecholamine excess can induce several other complications, such as hypertension, 4,7 seizure, 12 heart failure, 7 cardiomegaly, and symptoms mimicking early-onset sepsis 13 in patients with neuroblastoma. These catecholamine-induced symptoms are usually observed on admission, but sudden hypertension and lung edema caused by the induction of anesthesia, 14 exacerbation of hypertension on the day following the first dose of chemotherapy, 4 and hypertension that developed >100 days after the initiation of chemotherapy have also been reported.…”

Sinusknotendysfunktion mit intermittierendem Sinusarrest und AV-junktionaler Ersatzrhythmus als Erstmanifestation eines Phäochromozytoms

“…Zu den typischen Symptomen der Erkrankung zählen ein Hypertonus, der sich oft in Form krisenhafter Blutdruckanstiege manifestiert, aber auch Hypotonien, Kopfschmerzen, Schwitzen, Übel-keit und Palpitationen (2,7). Häufig beschriebene kardiale Symptome sind tachykarde Rhythmusstörungen in Form supraventrikulärer oder ventrikulärer Tachykardien oder komplexer ventrikuläre Extrasystolen (11).…”