SUN-074 - Atypical Pheochromocytoma Masquerading as Refractory Hypertension

Pheochromocytoma is a rare neuroendocrine tumor arising from the chromaffin cells of the adrenal medulla that releases hormones in the bloodstream when stimulated by the sympathetic nervous system. These tumors secrete excessive catecholamines primarily norepinephrine and epinephrine, which activate various receptors around the body leading to the hallmark symptoms seen in the disease. Norepinephrine causes peripheral vasoconstriction through the stimulation of alpha adrenergic receptors. On the other hand, epinephrine increases heart rate through the stimulation of beta adrenergic receptors. Together, the combined effect presents as the triad of headache, diaphoresis, and palpitations; however, presentation may be incomplete leading to delayed recognition and diagnosis. We present to you an atypical presentation of the tumor where the diagnosis was nearly missed until the patient was evaluated by her cardiologist. A 26-year-old female reported complaints of multiple elevated blood pressure readings at home. She had recently been evaluated by her neurologist and was found to have no acute findings after presenting with a history of headaches. Her blood pressure in the office was 138/110 mmHg with a reported reading of 217/98 mmHg at home. Antihypertensive therapy was initiated, yet her hypertension remained out of control despite optimizing medical treatment with a beta blocker, calcium channel blocker, and an ACE inhibitor. The lack of diaphoresis and palpitations masked the diagnosis and favored more common etiologies early in the course. Despite this, a urine study was ordered nonetheless for broader evaluation of the patient’s condition. It revealed elevated levels of catecholamines, metanephrines, and normetanephrines. CT scan was performed which confirmed pheochromocytoma. The patient was then referred for tumor resection which ultimately lowered her blood pressure and resolved additional catecholamine-related complaints. In the setting of absent diaphoresis and a previously unrevealing neurologic evaluation, the correct diagnosis and treatment was delayed. The patient’s condition could have easily been misdiagnosed as essential hypertension or a headache disorder due to failure of proper recognition of symptoms. This case highlights the importance of keeping a strong clinical suspicion for secondary causes in patients with incomplete presentation. It also emphasizes using a problem-based approach to patient care where disease differential is made using the presenting symptoms rather than using a checklist.

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