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Begum J, Kumari S, Ali M, Kumar Jena S, Behera K, Mishra P. A Misleading Presentation of Pheochromocytoma in Pregnancy: A Case Report. Medeni Med J 2021; 36:69-74. [PMID: 33828893 PMCID: PMC8020182 DOI: 10.5222/mmj.2021.29660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 01/20/2021] [Indexed: 11/25/2022] Open
Abstract
Pheochromocytoma is a catecholamine-secreting adrenal tumor and also a rare cause of secondary hypertension in pregnancy. Its low prevalence, nonspecific clinical presentation, and symptoms similar to preeclampsia generate a diagnostic challenge during pregnancy. A 23-year-old hypertensive pregnant woman at 36th gestational week of her first pregnancy was admitted with severe hypertension (210/150 mmHg), headache and proteinuria that made us presume the case as severe preeclampsia. In spite of starting with maximum doses of antihypertensive medications like IV labetolol,and oral nifedipine, loading dose of an anticonvulsant drug, and IV magnesium sulphate, her symptoms persisted. Keeping in view the risks involved to mother and fetus, we delivered the baby by emergency cesarean section. In the postoperative period, along with severe uncontrolled hypertension, she developed tremors, palpitation, and sweating that all led us to further diagnostic workup for secondary causes of hypertension. Eventually, a diagnosis of pheochromocytoma was confirmed by abdominopelvic contrast- enhanced computed tomography and by increased 24-hour urine metanephrine, normetanephrine, and vanillylmandelic acid levels. Subsequently, adrenal suppression was achieved by a multidisciplinary approach, and then she underwent laparoscopic adrenalectomy. This case highlights the importance of maintaining a high index of suspicion and multidisciplinary approach while investigating secondary causes of hypertension in young women, thereby differentiating it from preeclampsia.
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Affiliation(s)
- Jasmina Begum
- All India Institute of Medical Sciences, Department of Obstetrics and Gynecology, Bhubaneswar, India
| | - Supriya Kumari
- All India Institute of Medical Sciences, Department of Obstetrics and Gynecology, Bhubaneswar, India
| | - Manwar Ali
- All India Institute of Medical Sciences, Department of General Surgery, Bhubaneswar, India
| | - Saubhagya Kumar Jena
- All India Institute of Medical Sciences, Department of Obstetrics and Gynecology, Bhubaneswar, India
| | - Kishore Behera
- All India Institute of Medical Sciences, Department of Endocrinology, Bhubaneswar, India
| | - Pritinanda Mishra
- All India Institute of Medical Sciences, Department of Pathology, Bhubaneswar, India
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Ilias I, Thomopoulos C. Addressing delays in the diagnosis of pheochromocytoma/paraganglioma. Expert Rev Endocrinol Metab 2019; 14:359-363. [PMID: 31429343 DOI: 10.1080/17446651.2019.1657007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 08/14/2019] [Indexed: 12/27/2022]
Abstract
Introduction: Pheochromocytomas/paragangliomas (PPG) are rare tumors. In theory the diagnosis of PPG should be straightforward. In clinical practice, however, considerable delays are noted in establishing such a diagnosis. Areas covered: We assess the characteristics of various approaches to diagnosis and localization of PPG lesions (and their relevant caveats). We also evaluate potential biases to diagnosis. Expert opinion: A high degree of suspicion - particularly in younger patients - is required by clinicians. The availability of diagnostic means (mainly of biochemical tools) to establish the diagnosis of PPG should be increased.
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Affiliation(s)
- Ioannis Ilias
- Department of Endocrinology, Elena Venizelou Hospital , Athens , Greece
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Abstract
Pheochromocytoma during pregnancy is rare but potentially harmful to the mother and fetus. Fetal risks are mainly determined by the vasoconstrictive effects of maternal catecholamine on uteroplacental circulation, because the fetus is protected from the direct effects of high catecholamine levels at the placental interface. Uteroplacental insufficiency may lead to spontaneous abortion, fetal growth restriction, premature delivery, and fetal hypoxia, followed by fetal distress and/or birth asphyxia. Adrenalectomy is recommended during the second trimester. When a diagnosis is made during the late second or third trimester, appropriate medical treatment until term and planned delivery with concurrent or delayed adrenalectomy can result in good fetal outcomes. Moreover, when adrenalectomy is planned after delivery, there is concern regarding the potential of antihypertensive drugs to be transferred to breast milk. It is generally known that early detection and proper treatment of pheochromocytoma during pregnancy decrease maternal and fetal mortality. However, in recent case series, antenatal maternal pheochromocytoma diagnosis did not significantly decrease the risk of fetal and neonatal mortality and morbidity, contrary to the maternal death and complication rates. Although intrauterine ischemia and hypoxia due to uteroplacental insufficiency can affect the long-term outcomes of neonates, no systematic studies have been performed.
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Affiliation(s)
- Shigeo Iijima
- a Department of Regional Neonatal-Perinatal Medicine , Hamamatsu University School of Medicine , Shizuoka , Japan
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Donatini G, Kraimps JL, Caillard C, Mirallie E, Pierre F, De Calan L, Hamy A, Larin O, Tovkay O, Cherenko S. Pheochromocytoma diagnosed during pregnancy: lessons learned from a series of ten patients. Surg Endosc 2018; 32:3890-3900. [PMID: 29488089 DOI: 10.1007/s00464-018-6128-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 02/23/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Pheochromocytoma (PHEO) in pregnancy is a life-threatening condition. Its management is challenging with regards to the timing and type of surgery. METHODS A retrospective review of the management of ten patients diagnosed with pheochromocytoma during pregnancy was performed. Data were collected on the initial diagnostic workup, symptoms, treatment, and follow-up. RESULTS PHEO was diagnosed in ten patients who were between the 10th and the 29th weeks of pregnancy. Six patients had none to mild symptoms, while four had complications of paroxysmal hypertension. Imaging investigations consisted of MRI, CT scan and ultrasounds. All had urinary metanephrines, measured as part of their workup. Three patients had MEN 2A, one VHL syndrome, one suspected SDH mutation. All patients were treated either with α/β blockers or calcium channel blockers to stabilize their clinical conditions. Seven patients underwent a laparoscopic adrenalectomy before delivery. Three out of these seven patients had a bilateral PHEO and underwent a unilateral adrenalectomy of the larger tumor during pregnancy, followed by a planned cesarean section and a subsequent contralateral adrenalectomy within a few months after delivery. Three patients had emergency surgery for maternal or fetal complications, with C-section followed by concomitant or delayed adrenalectomy. All newborns from the group of planned surgery were healthy, while two out three newborns within the emergency surgery group died shortly after delivery secondary to cardiac and pulmonary complications. CONCLUSIONS PHEO in pregnancy is a rare condition. Maternal and fetal prognosis improved over the last decades, but still lethal consequences may be present if misdiagnosed or mistreated. A thorough multidisciplinary team approach should be tailored on an individual basis to better manage the pathology. Unilateral adrenalectomy in a pregnant patient with bilateral PHEO may be an option to avoid the risk of adrenal insufficiency after bilateral adrenalectomy.
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Affiliation(s)
- G Donatini
- Department of General and Endocrine Surgery, CHU Poitiers, 2 Rue de la Miletrie, 86021, Poitiers, France.
| | - J L Kraimps
- Department of General and Endocrine Surgery, CHU Poitiers, 2 Rue de la Miletrie, 86021, Poitiers, France
| | - C Caillard
- Department of General and Endocrine Surgery, CHU Nantes, Nantes, France
| | - E Mirallie
- Department of General and Endocrine Surgery, CHU Nantes, Nantes, France
| | - F Pierre
- Department of Obstetrics and Gynaecology, CHU Poitiers, Poitiers, France
| | - Loïc De Calan
- Department of General and Endocrine Surgery, CHU Tours, Tours, France
| | - A Hamy
- Department of General and Endocrine Surgery, CHU Angers, Angers, France
| | - O Larin
- Department of Endocrine Surgery, Ukrainian Scientific and Practical Center for Endocrine Surgery of Public Health Ministry of Ukraine, Kiev, Ukraine
| | - O Tovkay
- Department of Endocrine Surgery, Ukrainian Scientific and Practical Center for Endocrine Surgery of Public Health Ministry of Ukraine, Kiev, Ukraine
| | - S Cherenko
- Department of Endocrine Surgery, Ukrainian Scientific and Practical Center for Endocrine Surgery of Public Health Ministry of Ukraine, Kiev, Ukraine
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Pheochromocytoma Presenting as Partial HELLP Syndrome. Case Rep Obstet Gynecol 2015; 2015:294326. [PMID: 26351602 PMCID: PMC4553187 DOI: 10.1155/2015/294326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 08/03/2015] [Accepted: 08/11/2015] [Indexed: 12/03/2022] Open
Abstract
Diagnosis of pheochromocytoma in partial HELLP syndrome is extremely rare. We report a case of a 25-year-old multigravida woman at 30 weeks of gestation who presented with clinical features consistent with partial HELLP syndrome. Her symptoms were not controlled by pharmacologic therapy, and the patient underwent urgent cesarean section. The patient gave birth to a viable baby, but she sustained an episode of ventricular fibrillation intraoperatively that did not result in any long-term sequelae. The patient's symptoms persisted postoperatively and work-up for secondary etiologies of hypertension demonstrated a right adrenal pheochromocytoma. Following resection, the patient's signs and symptoms resolved, and her lab tests normalized.
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Abstract
Adrenal diseases, including Cushing syndrome (CS), primary aldosteronism (PA), pheochromocytoma, and adrenocortical carcinoma, are uncommon in pregnancy; a high degree of clinical suspicion must exist. Physiologic changes to the hypothalamus-pituitary-adrenal axis in a normal pregnancy result in increased cortisol, renin, and aldosterone levels, making the diagnosis of CS and PA in pregnancy challenging. However, catecholamines are not altered in pregnancy and allow a laboratory diagnosis of pheochromocytoma that is similar to that of the nonpregnant state. Although adrenal tumors in pregnancy result in significant maternal and fetal morbidity, and sometimes mortality, early diagnosis and appropriate treatment often improve outcomes.
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Affiliation(s)
- Deirdre Cocks Eschler
- Endocrinology Division, Department of Medicine, Stony Brook University School of Medicine, HSC T15-060, Stony Brook, NY 11794, USA.
| | - Nina Kogekar
- Department of Medicine, Mount Sinai School of Medicine, 1 Gustave L Levy Place, New York, NY 10029, USA
| | - Rachel Pessah-Pollack
- Endocrinology Division, Department of Medicine, Mount Sinai School of Medicine, 1 Gustave L Levy Place, New York, NY 10029, USA; Department of Endocrinology, ProHealth Care Associates, Ohio Drive, Lake Success, NY 11042, USA
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Takahashi N, Nishijima K, Orisaka M, Tsuyoshi H, Kurokawa T, Kato K, Shirafuji A, Arakawa K, Hisazaki K, Tada H, Yoshida Y. Amniotic Fluid Embolism Triggered By Hypertensive Crisis Due to Undiagnosed Pheochromocytoma in a Pregnant Subject With Neurofibromatosis Type 1. AACE Clin Case Rep 2015. [DOI: 10.4158/ep14108.cr] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Pereira-da-Silva T, Abreu J, Ramos R, Galrinho A, Fortuna P, Tavares NJ, Ferreira RC. Unexpected triggers for pheochromocytoma-induced recurrent heart failure. Int Arch Med 2014; 7:30. [PMID: 24987459 PMCID: PMC4077553 DOI: 10.1186/1755-7682-7-30] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Accepted: 06/16/2014] [Indexed: 05/28/2023] Open
Abstract
Pheochromocytoma crisis typically presents as paroxysmal episodes of headache, tachycardia, diaphoresis or hypertension. We describe an uncommon case of recurrent non-hypertensive heart failure with systolic dysfunction in a young female due to pheochromocytoma compression. It presented as acute pulmonary oedema while straining during pregnancy and later on as cardiogenic shock after a recreational body massage. Such crisis occurring during pregnancy is rare. Moreover, of the few reported cases of pheochromocytoma-induced cardiogenic shock, recreational body massage has not yet been reported as a trigger for this condition.
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Affiliation(s)
- Tiago Pereira-da-Silva
- Department of Cardiology, Hospital de Santa Marta, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - João Abreu
- Department of Cardiology, Hospital de Santa Marta, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - Ruben Ramos
- Department of Cardiology, Hospital de Santa Marta, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - Ana Galrinho
- Department of Cardiology, Hospital de Santa Marta, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - Philip Fortuna
- Emergency and Intensive Care Department, Hospital de São José, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | | | - Rui Cruz Ferreira
- Department of Cardiology, Hospital de Santa Marta, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
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