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

Case report

Case report

Suspected pheochromocytoma the best plan would be to do Metanephrin/plasma and 24h

Catecholamine/ urine Surgery (BD hospital) But… BD Endocrinologist/ Medic

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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