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Fever of Unknown Origin: Could It Be a Pheochromocytoma? A Case Report and Review of the Literature. Case Rep Endocrinol 2018; 2018:3792691. [PMID: 30057828 PMCID: PMC6051277 DOI: 10.1155/2018/3792691] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Revised: 06/05/2018] [Accepted: 06/10/2018] [Indexed: 01/30/2023] Open
Abstract
Pheochromocytomas are rare tumors that arise from the adrenal medulla, with an incidence of less than 1 per 100,000 person-years. These tumors are characterized by excess catecholamine secretion and classically present with the triad of headaches, palpitations, and sweating episodes. However, the clinical presentation can be quite variable. Herein, we present a patient who presented with persistent fevers. An adrenal mass was incidentally discovered during the extensive investigation for the fever of unknown origin. Consequently, blood and urine tests were done and found to be consistent with a pheochromocytoma. The resection of this pheochromocytoma resulted in resolution of fevers. It is hypothesized that fevers in patients with pheochromocytomas occur due to the excess catecholamine or possibly due to interleukins. This clinical presentation serves as a learning point that adrenal incidentalomas in the setting of fever of unknown origin should not be ignored. It also reminds clinicians that pheochromocytomas which present with fevers may have tumor necrosis and many such patients are at risk for multisystem crises.
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Moretti A, Minuto M, Berti P, Bernini GP, Mannelli M, Miccoli P. Unusual association of adrenal pheochromocytoma and para-aortic neurofibroma in pregnancy. J Endocrinol Invest 2006; 29:738-41. [PMID: 17033264 DOI: 10.1007/bf03344185] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The association of pheochromocytoma (PHEO) and pregnancy is uncommon and life threatening for both the fetus and the mother. Early diagnosis and treatment is essential to decrease maternal and fetal mortality and to differentiate the disease from the more common pre-eclampsia. While medical treatment should be started immediately after diagnosis, the timing of surgical treatment is still debated. We describe the case of a 27-yr-old woman in the 18th week of pregnancy who showed a biochemical pattern typical of PHEO and, by imaging studies, 2 tumors with the same characteristics: the first localized on the right adrenal gland, the second at the right renal hilum. The patient underwent surgery because of suspicion of malignant PHEO with local metastasis, while histology revealed a rare association of a solitary PHEO and para-aortic neurofibroma, both tumors embryologically deriving from a common cell precursor.
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Affiliation(s)
- A Moretti
- Department of Internal Medicine, University of Pisa, 56100 Pisa, Italy
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Preuss J, Woenckhaus C, Schwesinger G, Madea B. Non-diagnosed pheochromocytoma as a cause of sudden death in a 49-year-old man: a case report with medico-legal implications. Forensic Sci Int 2005; 156:223-8. [PMID: 15982839 DOI: 10.1016/j.forsciint.2005.05.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2004] [Revised: 05/16/2005] [Accepted: 05/16/2005] [Indexed: 10/25/2022]
Abstract
Pheochromocytomas are known to be rare causes of sudden death. A 49-year-old man with a medical history of arterial hypertension and diabetes mellitus complained about nausea and malaise in the morning. During the day his condition deteriorated. He went to the emergency department, where he was given intravenous drugs against nausea and was sent home. On the way back, his condition deteriorated dramatically so that his wife drove back to the emergency room, where he collapsed and sustained cardiac arrest; resuscitation efforts were unsuccessful. Autopsy revealed a large tumour of the left adrenal gland. The strong suspicion of pheochromocytoma was confirmed by histology, immunohistochemistry and biochemical investigations. An acute hypertensive crisis, caused by the hitherto unknown pheochromocytoma was ascertained as the cause of death. The morphological findings are presented, the difficulty to diagnose pheochromocytoma and the medico-legal implications are discussed.
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Affiliation(s)
- J Preuss
- Institute of Forensic Medicine, University of Bonn, Stiftsplatz 12, D-53111 Bonn, Germany.
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Abstract
Numerous medical, surgical, psychiatric, gynecologic, and obstetric disorders can cause abdominal pain during pregnancy. The patient history, physical examination, laboratory data, and radiologic findings usually provide the diagnosis. The pregnant woman has physiologic alterations that affect the clinical presentation, including atypical normative laboratory values. Abdominal ultrasound is generally the recommended radiologic imaging modality; roentgenograms are generally contraindicated during pregnancy because of radiation teratogenicity. Concerns about the fetus limit the pharmacotherapy. Maternal and fetal survival have recently increased in many life-threatening conditions, such as ectopic pregnancy, appendicitis, and eclampsia, because of improved diagnostic technology, better maternal and fetal monitoring, improved laparoscopic technology, and earlier therapy.
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Affiliation(s)
- Mitchell S Cappell
- Division of Gastroenterology, Department of Medicine, Woodhull Medical Center, 760 Broadway Avenue, Brooklyn, NY 11206, USA
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Abstract
OBJECTIVE To report eight cases of pheochromocytoma, diagnosed and treated at our tertiary hospital during a 42-month period. METHODS We review clinical manifestations as well as historical and family data. Biochemical and radiologic methods for diagnosis and tumor localization at our institution were compared with methods at other teaching centers. RESULTS Among 4,180 patients with essential hypertension encountered during a 42-month interval, 8 had pheochromocytoma. The most common clinical findings were diaphoresis, chest or abdominal pain, palpitations, headaches, and nausea. Clinical features were remarkable only for the significant correlation between urinary excretion of vanillylmandelic acid and tumor volume (r = 0.925; P<0.01). Only one patient, with a history of medullary thyroid carcinoma, had multiple endocrine neoplasia. No unusual familial concentration of pheochromocytomas was found in our community, and our diagnostic techniques were similar to those reported from other institutions. We calculated an average annual incidence rate of 0.5 per 100,000 person-years, a figure comparable to that reported at the Mayo Clinic in Rochester, Minnesota. CONCLUSION Because our institution does not see the volume of referral patients as does the Mayo Clinic, we suggest that the frequency of pheochromocytoma may be underestimated in the patient population that we serve.
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Affiliation(s)
- M Ariton
- Division of Endocrinology and Metabolism, Department of Medicine and Pediatrics, The Brookdale University Hospital and Medical Center, Health Sciences Center at Brooklyn, State University of New York, Brooklyn, New York 11212-3198, USA
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Ahlawat SK, Jain S, Kumari S, Varma S, Sharma BK. Pheochromocytoma associated with pregnancy: case report and review of the literature. Obstet Gynecol Surv 1999; 54:728-37. [PMID: 10546277 DOI: 10.1097/00006254-199911000-00025] [Citation(s) in RCA: 103] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED We report on a young woman with pheochromocytoma associated with pregnancy and review 41 other cases reported in the literature from 1988 to 1997. This review reveals that the overall maternal mortality was 4 percent and the fetal loss 11 percent; antenatal diagnosis of pheochromocytoma reduced maternal mortality to 2 percent; however, fetal loss was 14 percent. Diagnosis of pheochromocytoma was made antepartum in 83 percent of the cases. Although pheochromocytoma associated with pregnancy is rare, a high index of clinical suspicion must be kept and all those at risk must be investigated to achieve an early diagnosis and improved outcome. Once the diagnosis is confirmed, alpha-adrenergic blockade is essential and beta-blockade may be required. Magnetic resonance imaging and computerized tomography scan may be used to localize the tumor during the antenatal period. In early pregnancy, i.e., before 24 weeks, both tumor resection and medical treatment are associated with good fetal outcome; in later pregnancy, elective cesarean delivery followed by tumor resection results in favorable maternal and fetal outcome. TARGET AUDIENCE Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES After completion of this article, the reader will be able to understand the clinical manifestations of a pheochromocytoma during pregnancy, how to make the diagnosis of a pheochromocytoma during pregnancy, and to know the medical and surgical management of a pheochromocytoma during pregnancy.
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Affiliation(s)
- S K Ahlawat
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Eclavea A, Gagliardi JA, Jezior J, Burton B, Donahue JP. Phaeochromocytoma with central nervous system manifestations. AUSTRALASIAN RADIOLOGY 1997; 41:373-6. [PMID: 9409033 DOI: 10.1111/j.1440-1673.1997.tb00737.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
A 35-year-old Samoan male presented with intermittent headaches and hypertensive episodes for several months. A subsequent left adrenal gland phaeochromocytoma was discovered and surgically excised. An MRI of his brain demonstrated periventricular, basal ganglia, and centrum semi-ovale infarction. We suggest that catecholamine excess and neuropeptide Y may contribute to intracerebral haemorrhage and infarcts associated with phaeochromocytomas. Additionally, our surgical approach in removing the phaeochromocytoma is discussed.
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Affiliation(s)
- A Eclavea
- Tripler Army Medical Centre, Department of Radiology, Hawaii, USA
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Evans JP, Bambach CP, Andrew S, Dwight T, Richardson AL, Robinson BG, Delbridge L. MEN type 2a presenting as an intra-abdominal emergency. THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 1997; 67:824-6. [PMID: 9397010 DOI: 10.1111/j.1445-2197.1997.tb04599.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- J P Evans
- Department of Surgery, Royal North Shore Hospital, St Leonards, New South Wales, Australia
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Baduí E, Lepe L, Van Wielink G, Espinosa R. Paroxysmal atrial tachycardia recorded by Holter monitoring during an episode of fear. A case report. Angiology 1996; 47:713-6. [PMID: 8686968 DOI: 10.1177/000331979604700713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
A twenty-four-year-old, white, athletic woman, free of heart disease, experienced an episode of fear when she was assaulted in the street without physical injury while under-going twenty-four-hour Holter monitoring. She developed an important sympathetic response in which, besides the symptoms characterized by palpitations, chest pain, dyspnea, asthenia, dizziness, nausea, and profuse cold sweating, she had an episode of paroxysmal atrial tachycardia. The causes and mechanism of this not well-documented event in humans are discussed.
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Affiliation(s)
- E Baduí
- Division de Cardiologia, Hospital de Especialidades, Centro Medico la Raza, Mexico, D.F
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Botchan A, Hauser R, Kupfermine M, Grisaru D, Peyser MR, Lessing JB. Pheochromocytoma in pregnancy: case report and review of the literature. Obstet Gynecol Surv 1995; 50:321-7. [PMID: 7783999 DOI: 10.1097/00006254-199504000-00028] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Pheochromocytoma is a rare disease that may occur during pregnancy. Only a few hundred cases have been published in the literature. Manifestations include hypertension with various clinical presentations, possibly resembling those of pregnancy-induced hypertension, or pre-eclamptic toxemia. Differentiation of these conditions is not always feasible, thus creating a serious risk, because fetal and maternal morbidity and mortality are far higher with pheochromocytoma. Biochemical measurements of catecholamines and their metabolites are apparently a convenient way to establish diagnosis during pregnancy, inasmuch as interpretation of radiological evaluation is complicated by the gravid uterus, and might even be potentially dangerous due to the use of ionizing radiation. More sophisticated methods for evaluation are not always practical during pregnancy. Medical treatment aims at controlling symptoms, mandating the use of alpha- and beta-receptors blockade medication. Surgical intervention is the only possible curative method available, but the critical issue is probably to identify the exact timing during the course of pregnancy for such intervention, or the ability to control symptoms until delivery. Although malignant transformation of pheochromocytoma have been reported, it is extremely uncommon. The overall prognosis is mainly affected by early diagnosis, and multidisciplinarian management.
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Affiliation(s)
- A Botchan
- Department of Obstetrics and Gynecology A, Serlin Maternity Hospital, Tel Aviv Sourasky Medical Center, Israel
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Nishikawa K, Yukioka H, Tatekawa S, Fujimori M. Phaeochromocytoma crisis in Sipple's syndrome with intrauterine death and disseminated intravascular coagulation. Int J Obstet Anesth 1993; 2:45-8. [PMID: 15636849 DOI: 10.1016/0959-289x(93)90030-l] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Unrecognized phaeochromocytoma during pregnancy is dangerous for both fetus and mother. We report here a case of phaeochromocytoma crisis in Sipple's syndrome associated with disseminated intravascular coagulation that developed following intrauterine death. Early evacuation of the uterus seems advisable, to rid the patient with phaeochromocytoma of further complications associated with fetal death.
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Affiliation(s)
- K Nishikawa
- Department of Anesthesiology and Intensive Care Medicine, Osaka City University Medical School, 1-5-7, Asahi-machi, Abeno-ku, Osaka, 545, Japan
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Affiliation(s)
- P Wajon
- Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, Sydney
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Harper MA, Murnaghan GA, Kennedy L, Hadden DR, Atkinson AB. Phaeochromocytoma in pregnancy. Five cases and a review of the literature. BRITISH JOURNAL OF OBSTETRICS AND GYNAECOLOGY 1989; 96:594-606. [PMID: 2667632 DOI: 10.1111/j.1471-0528.1989.tb03262.x] [Citation(s) in RCA: 147] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
We report five patients with phaeochromocytoma associated with pregnancy and review the 42 other cases reported in the literature from 1980 to 1987. The overall maternal mortality was 17% and the fetal loss 26%; antenatal diagnosis of phaeochromocytoma reduced the maternal mortality to zero and the fetal loss to 15%, but was made in only 53% of the patients. Although phaeochromocytoma is rare, a high index of clinical suspicion must be maintained and all those at risk investigated if earlier diagnosis and improved outcome are to be achieved. Once the diagnosis is confirmed, alpha-blockade is essential and beta-blockade may be required. CT scan or magnetic resonance imaging may be used to localize the tumour during the antenatal period. In the first and second trimesters, tumour resection has a good fetal outcome; in later pregnancy, delivery by elective caesarean section followed by tumour resection is recommended.
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Affiliation(s)
- M A Harper
- Department of Obstetrics and Gynaecology, Queen's University of Belfast
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