Reversible cerebral ischemia in patients with pheochromocytoma

Neurologic complications of disorders of the adrenal glands

Disorders of the adrenal glands frequently have secondary neurological manifestations, while some diseases that involve the central nervous system are accompanied by adrenal gland dysfunction. Excessive corticosteroid secretions in primary or secondary Cushing's syndrome causes muscle weakness and behavioral disturbances, such as emotional lability and sometimes depression, while adrenal insufficiency may cause fatigue, weakness, and depression. Adrenoleukodystrophy and adrenoneuromyelopathy are X-linked recessive disorders of the metabolism of very long chain fatty acids that manifest with white matter abnormalities of the brain, myelopathy and/or neuropathy, as well as adrenal insufficiency. Other disorders of the adrenal glands include hyperaldosteroidism, which may cause weakness from hypokalemia. Dysfunction of the adrenal medulla causes excessive or deficient secretion of catecholamines, primarily causing cardiovascular symptoms. This chapter reviews the clinical manifestations and diagnostic aspects and treatment of the various disorders of the adrenal glands. Some of the congenital adrenal diseases are also discussed.

Ischemic stroke and rhabdomyolysis in a 15-year-old girl with paraganglioma due to an SDHB exon 6 (Q214X) mutation

BACKGROUND

We report a 15-year-old girl with a recent diagnosis of type 2 diabetes mellitus who presented in malignant hypertensive crisis (BP 210/120 mm Hg). Abdominal CT showed an 8.2 x 4.7 x 7.0 cm mass in the region of the organ of Zuckerkandl. MIBG scan showed a single paraganglioma without metastatic foci. Plasma total metanephrines were 232,176.4 pmol/l [263-1052] with normetanephrine predominance. Pre-operative course was complicated by ischemic stroke in the left MCA and right thalamic regions, acute renal failure, rhabdomyolysis and congestive heart failure. She required massive doses of propranolol, phenoxybenzamine, doxazosin and metyrosine prior to surgery.

RESULTS

Pathology showed a Zellballen pattern, negative tumor margins and benign para-aortic lymph nodes. Mutation analysis of the succinate dehydrogenase type B (SDHB) gene revealed a heterozygous change of C to T at position 640 in exon 6 (Q214X) predicting an amino acid change to a stop codon.

CONCLUSION

We report a severe clinical phenotype in a patient with a paraganglioma affecting multiple organ systems, due to an SDHB mutation. SDHB mutation warrants close follow up and investigation of the family due to high malignant potential and risk of familial occurrence.

Pheochromocytoma presenting with bithalamic infarction, dementia, and increased intraocular pressure

The authors describe a case of pheochromocytoma presenting with bithalamic infarction, dementia, and elevated intraocular pressure. The patient received glaucoma treatment to suppress high intraocular pressure in addition to antihypertensive and antidiabetic medication for his complaints. Bilateral fundus examination and visual field defects revealed glaucoma-like changes. Adrenelectomy improved all complaints and all medications were stopped. Intraocular pressure and visual field changes improved. Pheochromocytoma presenting with bithalamic infarction, dementia, and increased IOP in the same patient is unusual. Adrenelectomy can improve dementia, increased IOP, and glaucoma-like changes in such cases.

Seizures as a presenting symptom of phaeochromocytoma in a young soldier

New onset of seizures in young adults is frequently related to alcohol withdrawal, toxic exposure, central nervous system trauma and neoplasm. We describe a young soldier presenting to the emergency department with seizures and transient coma. On admission, he had hypertension, marked leukocytosis, hyper-glycaemia, acidosis, elevated creatinine and elevated creatine phosphokinase of muscle origin. A thorough work-up revealed elevated urinary catecholamines, and a left adrenal mass was found on MRI and MIBG scan. The patient underwent laparoscopic adrenalectomy and completely recovered. This is the first description of seizures as a presenting symptom of phaeochromocytoma.

Pheochromocytoma presenting as stroke in two Taiwanese children

Pheochromocytoma is a rare tumor and accounts for about 1% of pediatric hypertension. Its diagnosis is important because the hypertension is usually curable by eradication of the tumor. We report two Taiwanese children with pheochromocytoma presenting as stroke. Patient 1 developed a cerebral infarction and patient 2 had an intracranial hemorrhage. Abdominal MRI of patient 1 showed an extraadrenal tumor 5.1 x 4 x 4.7 cm in size and abdominal CT of patient 2 revealed a left adrenal mass 4 x 2.9 x 4 cm in size. 24-h urinary excretion of norepinephrine for patients 1 and 2 were 1480.8 and 3279 microg/day, respectively. Preoperative alpha- and beta-adrenergic blockade was used for hypertension control. Both patients underwent successful tumor resection, upon which blood pressure and 24-h urinary excretion of catecholamines returned to normal without any further medication. They have been free from hypertension for 4 years (patient 1) and 2 years (patient 2).