Abstract 20755: Keeping Calm While Solving the Puzzle: An Uncommon Case of Hypertensive Emergency
A 50-year-old man with diabetes was transferred for non-ST segment elevation myocardial infarction. He presented with a 4-day history of chest pain, diaphoresis, nausea, vomiting, headache, and syncope. On arrival, he was afebrile with BP 263/192 mmHg, HR 155 bpm. Minutes later his blood pressure (BP) dropped to 60/30 mmHg, heart rate (HR) 60 bpm. The remainder of his exam was unrevealing. Labs were remarkable for Troponin I 2.28, WBC 17.2, anion gap 15, lactate 6, creatinine 1.28, glucose 406. Echo showed mildly decreased left ventricular ejection fraction of 50-55% and a large intraabdominal, echolucent, heterogeneous structure in the subcostal view of unclear etiology. Head CT showed left frontal subarachnoid hemorrhage. CT abdomen was ordered to evaluate the intraabdominal structure, but the patient developed narrow complex tachycardia at 180 bpm with SBP of 50 mmHg. Direct current cardioversion with 200 J was done twice but unsuccessful. Before a vasopressor could be started, his HR spontaneously decreased to sinus rhythm of 60 bpm and systolic BP increased to 250 mmHg. We proceeded with CT abdomen that demonstrated a hemorrhaging right suprarenal 10.7 x 7.4 cm mass. Given his presenting symptoms in combination with the labile BP and HR, the most likely diagnosis was ruptured pheochromocytoma. He was started on phenoxybenzamine and a nicardipine drip. The patient’s condition improved. Urine metanephrines were significantly elevated and MIBG scan showed right adrenal tracer uptake. Elective adrenalectomy confirmed a ruptured pheochromocytoma (Figure). This case of hypertensive emergency due to a ruptured pheochromocytoma demonstrates the importance of considering both history and clinical presentation to obtain the correct diagnosis, even in an emergent setting when time is limited. Attention to detail and refraining from making reflex decisions in situations where the pieces of the puzzle do not quite fit together is key.
Author Disclosures: M.F. Bode: None. W.D. Bode: None.
- © 2016 by American Heart Association, Inc.