Unusual presentation of phaeochromocytoma

Abstract

The anaesthetic management of patients with phaeochromocytoma is often difficult even when a clear-cut pre-operative diagnosis has been made. This report concerns a patient with a history of high output left ventricular failure, who presented for exploratory laparotomy and removal of a highly vascular tumour, and who intra-operatively was discovered to have a phaeochromocytoma. Case reportA 54-year-old insulin dependent diabetic of 22 years' standing first presented in June 1974, with an 8-week history of increasing exertional dyspnoea, orthopnoea, and paroxysmal nocturnal dyspnoea. Relevant clinical findings showed an obese male whose arterial pressure varied between lSO/lOO and 180/ 105 mmHg,* with peripheral oedema, elevated jugular venous pressure, and bilateral basal crepitations. Abdominal examination showed hepatomegaly and, below this, a rather ill-defined mass. Plain abdominal X-rays showed calcification within the liver, believed to be associated with this mass.The heart failure and hypertension were readily controlled with digoxin and diuretic therapy and the patient was discharged home on a weight-reducing diet and increased insulin dosage. On direct questioning he gave a past history of trauma to the liver area, and so it was felt that the calcified mass was probably an old haematoma.Eight months later he was re-admitted for investigation, because of rapidly increasing insulin requirements, a 19 kg weight loss, nocturnal bowel frequency, increased sweating, and hypertension. On this occasion abdominal examination showed a large liver and, below it, a cyst-like rounded mass over which could be heard a loud bruit. A liver scan confirmed a filling defect in the right lobe of the liver, compatible with the calcified mass previously seen on plain X-ray. Haematological investigations showed a haemoglobin of 10.9 g/dl, an ESR of 125 mm per hour, and grossly elevated values