Document Type

Conference Proceeding

Publication Date

5-2-2025

Abstract

Introduction/Background: The prevalence of adrenal incidentalomas varies between 1.4-7.3% rising with age due to an increase in imaging studies performed for other reasons. Additional workup is typically done to evaluate for presence of functional masses that over secrete hormones. Elevated catecholamines in the context of an adrenal mass should trigger clinical suspicion for pheochromocytoma, an adrenal medulla tumor. However, for isolated elevations in normetanephrines a broader differential should include paraganglioma as well as stress, certain foods, and medication side effects requiring a thorough history and clinical evaluation. We present a case of an adrenal mass with elevated normetanephrine levels in a relatively asymptomatic patient with progression of symptoms after a stressor. Clinical Case: A 59 y/o female with a remote history of migraine headaches and hypertension diagnosed 2 years prior to presentation controlled on hydrochlorothiazide presented to clinic for evaluation of a right adrenal nodule. She underwent abdominal ultrasound for abnormal liver function lab results. The ultrasound incidentally found a 3.5 cm soft tissue nodule in the region of the right adrenal gland. CT study with contrast confirmed presence of 3.4 cm mass in right adrenal gland consistent with lipid poor adenoma measuring 39 Hounsfield units pre-contrast. At the time of her visit the patient denied any sweating, palpitations, headaches. Blood pressure at time of visit was 130/70, BMI was 26.08. Lab work revealed elevated serum free normetanephrines at 3.6, elevated urine metanephrines and catecholamines which were predominantly norepinephrine. Additional workup for aldosterone secreting or cortisol secreting mass was unremarkable. She had no prior family history of paragangliomas upon further questioning. MRI of the abdomen showed 3.4 cm stable mass in the right adrenal gland most consistent with pheochromocytoma, and no additional suspicious lesions. She was referred to endocrine surgery with plans to proceed with elective adrenalectomy, however she was lost to follow up. Approximately 5 months later she presented to an urgent care for symptoms consistent with a UTI and blood pressure was found to be 154/87 likely due to excess catecholamine release from stress on top of likely existing pheochromocytoma. During follow up in clinic 2 months after repeat lab work showed interval increase in urine metanephrines and catecholamine levels, repeat imaging showed stable size of mass with no new additional abdominal findings. Patient was referred to endocrine surgery for adrenalectomy given worsening symptoms and concern for future noncompliance in the event of anesthesia. Patient completed resection of right adrenal gland after appropriate perioperative alpha and beta blockade with resolution of abnormal urine and serum free metanephrine levels. Pathology confirmed pheochromocytoma. Genetic testing was negative for any pathologic variants for pheochromocytoma or paraganglioma. Conclusion/Clinical Lesson: Catecholamine over secretion can have serious consequences if left undiagnosed and untreated. This case serves to highlight the presence of hormone secreting tumors in patients with mild or absent symptoms and the need for a broad differential including pheochromocytoma and paraganglioma. It also demonstrates the need for adequate patient counseling and shared decision making to help ensure and prevent delays in necessary treatment.

Comments

American College of Physicians Michigan Chapter and Society of Hospital Medicine Michigan Chapter Resident and Medical Student Day, May 2, 2025, Troy, MI

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