SENIOR TALK Pratima Sood, M.D. CASE PRESENTATION
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Pratima Sood, M.D.
19 y.o man presents with episodic mild headaches that resolve spontaneously. Two months before presentation, the headaches became more severe and frequent, occurring almost daily, and were accompanied by throbbing chest pain, sweating, dizziness, and palpitations. During episodes of severe headache, BP was >235/135 mmHg.
SHx: Denies tobacco, EtOH, or IVDA
FHx: Father had HTN in 50s; Mother had migraines
T: 36.6, BP 140/70 mmHg, HR 72
GEN: NAD; AAO x3; Appears well
HEENT: Carotid upstrokes were bounding
CV: Cardiac apical impulse was prominent
ABD: Soft; NT/ND; BS+
EXT: No C/C/E
ECG: PR interval 128msec, nonspecific ST-segment and T-wave abnormalities with prominent voltage.
Lab studies are all WNL, except phosphorus level was 4.8 mg per dL; Serum and urine tox screen were negative.
CT scan of head without contrast showed no abnormalities.
CT scan of abdomen and pelvis with oral contrast was unremarkable.
Renal MRI scan showed a well-demarcated mass, 3 x 2.4 x 2.2cm in the hilum of the right kidney. The right kidney had two renal arteries, the upper artery appeared normal, lower artery compressed by the mass.
Glomerulonephritis; Renovascular HTN
Meds (MAOIs, decongestants, PCP, LSD, Cocaine, Sympathomimetics)
Rare catecholamine-secreting tumor derived from chromaffin cells of adrenal medulla.
PARAGANGLIOMAS ("extra-adrenal pheochromocytomas") are tumors that arise from sympathetic paraganglia . Rarely in locations as the thorax, bladder, or brain.
The classic triad of symptoms consists of EPISODIC headache, sweating, and tachycardia in association with severe hypertension. Can also include:
Anxiety, sense of doom
Epigastric and/or flank pain
Young, WF Jr. Pheochromocytoma: 1926-1993. Trends in Endocrinology and Metabolism, vol 4, Elsevier Science, Inc 1993. p 122.
36 y.o man is evaluated for headache & palpitations. He is anxious, tremulous, & diaphoretic. BP is 198/106, HR is 110. Hypertension has been suboptimally controlled with HCTZ, diltiazem, and lisinopril. He frequently experiences similar episodic headache and diaphoresis, during which his BP is alarmingly high. Propranolol worsened their frequency and severity.
Which of the following tests would be most appropriate next step in management of this patient?
42 y.o man is evaluated for an anterior neck mass. He has a family history of thyroid cancer and hyperparathyroidism. BP is 147/85, HR is 88; has a 3-cm right thyroid nodule and bilateral anterior cervical lymphadenopathy. Cardiac exam reveals a 2/6 systolic ejection murmur. Labs show serum TSH of 1.4, calcium of 10.6, and microscopic hematuria. FNA of the nodule suggests medullary thyroid cancer.
Which of the following tests is the most appropriate next test in the evaluation of this patient?
45 y.o woman with hypertension refractory to therapy with maximal doses of a diuretic, ACEIs, and CCBs is found to have markedly elevated fractionated plasma metanephrines. A 24-hour urine collection for metanephrines contains three times the normal daily excretion for a hypertensive patient. Which of the following is the most appropriate next step in the evaluation of this patient?
22 y.o woman presents for screening because of a family history of medullary thyroid carcinoma. PE reveals BP 155/105, a 1-cm left thyroid mass. She has no mucosal neuromas. Lab studies:
Calcium 10.9; Phos 2.6; Chloride 108; Intact PTH 52; Calcitonin 350
Urine calcium excretion 382 mg/24 h; Urine catecholamines excretion 281 µg/24h
Which of the following is the most appropriate next step in management?
38 y.o woman is found to have a 3-cm heterogeneous mass in the right adrenal gland during evaluation for abdominal discomfort. Plasma fractionated metanephrines are twice the upper limit of normal. 24hour urine collection for metanephrines contains 2.5 times the normal daily excretion. Pheochromocytoma is suspected and laparoscopic adrenalectomy is planned within the next 14 to 21 days. BP is 206/110, and HR is 104.
Which of the following would be indicated first before surgery?