PHEOCHROMOCYTOMA and DIABETES MELLITUS
Case report
BS LÊ HỮU QUỲNH TRANG
Case report
50M Chief complaint: episodes of HTN and
palpitations History:
-2006 HTN, crisis, max SBP 230mmHg, headache, dizziness, excessive sweating… had to admit to hospital-2007 DM2-Jan 2014 : gastric hemorrhage
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Feb 2014: check-up at MEDIC-> suspected tumor of the left adrenal gland Follow up
Still have the above symptoms ->cardiac consult
Family history: his brother has mild hypertension
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Examination: Rosacea rhynophymaBP 130/80mmHg,P 105 pbm, H 172, W 62Recently taking: Glyclazid 30 3tabs, Metformin 850 2tabs, Lercanidipin 10mg daily
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Case report
Case report
Theo doõi u tuyeán thöông thaän traùi
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Case report
Suspected pheochromocytoma the best plan would be to do Metanephrin/plasma and 24h
Catecholamine/ urine Surgery (BD hospital) But… BD Endocrinologist/ Medic
Case report
Plasma metanephrin: 71.55 ( N<90 pg/ml)
Cortisol/urine: 251.36 (21-134µg/24h) (V1600ml)
Overnight dexamethasone suppression test: 1.5 µg/dl (rule out Cushing syndrome <1.8 µg/dl )
Cortisol/ Blood (Morning): 18.8 (6-19.4µg/dl)
Aldosterone: 10.6 (2.5-31.5ng/dl upright, 1.3-16ng/dl supine)
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Endocrinologist: hormonally inactive adrenal tumor Follow- up
Come back cardiac consult for palpitations( a month later):
Clinical context: HTN, DM2, episode of sweating, palpitations and headache
Images: Left adrenal tumor Laboratory test: normal metanephrin Hormonally inactive adrenal tumor by Endocrinologist
Still suspected Pheochromocytoma 24h catecholamine/urine
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An Surgery in115 Hospital (Insurance)enion is worth a pound of cure
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-After operation: no longer HTN, DM2
Discussion
Pheochromocytoma is defined as chromaffin cells derived catecholamine-producing tumor of adrenal medulla.Named by Ludwig Pick , pathologist, 1912
The first surgical removal of a pheochromocytoma was performed by Cesar Roux in 1926 in Europe and by Charles Mayo in the USA in 1927.
A rare tumor with incidence of only 0.1% even which is found incidently, occurs in 0.1-1% of hypertensive patients.
Symptoms
Symptoms: Pheochromocytoma (or 3P) and hypertension
Palpitations Headache (pain) Episodes of sweating (perspiration)
Symptoms
Pheochromocytoma
The spells : -from monthly to several times per day -the duration may vary from seconds
to hours. Paroxysms may be precipitated by
-physical training-contrast media-tricyclic antidepressive drugs-metoclopramide and opiates
Pheochromocytoma: The Ten-Percent Tumor
10% extra-adrenal (closer to 15%) 10% occur in children 10% familial
10% bilateral or multiple (more if familial) 10% recur (more if extra-adrenal) 10% malignant 10% discovered incidentally
1. MEN 2 syndromes (multiple endocronological neoplasia) 2. VonHippel-Lindau‘s Diseases3. Neurofibromatosis type 14. Familial Paraganglioma Syndrome
Pheochromocytoma
Pheochromocytoma
The Washington Manual: Endocrinology
False positive plasma metanephrine
False negative plasma metanephrine
<2 cm in size DA-producing pheochromocytomas
->Recheck with a spell->24-hour urine total metanephrines and catecholamines
Pheochromocytoma and DM
Epinephrin > Norepinephrin in producing hyperglycemia because of its higher affinity to the β-2 adrenergic receptors.
In the pancreas : Epinephrine inhibits insulin secretion mostly by stimulating α-2 adrenergic receptor and probably by inducing glucagon secretion via β adrenergic receptor
In the liver : Epinephrine increases transient glycogenolysis and sustained gluconeogenesis by stimulating β-2 adrenergic receptors
Pheochromocytoma and DM
DM in patients with pheochromocytoma :2–5%
Impaired glucose tolerance :12–75% Very rarely, a patient with a
pheochromocytoma may present in diabetic ketoacidosis.
In young patients with HTN and normal body weight, the presence of DM is a clinical clue to the diagnosis of pheochromocytoma
J Clin Endocrinol Metab 2003;88(8):3632-36J Hypertens 2003Sep; 21(9):1703-7
CONCLUSIONS
Rare opportunity to “kill two birds with one stone”
Clinical context is always important Skill of ultrasound doctor Added 24-hour urine total
metanephrines and catecholamines /Medic test list.
Thanks for your attention
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