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Presentation

A 36-year-old female presented to the emergency department with a 1-day history of severe nausea and vomiting after exertion. She had experienced recurrent episodes of nausea and vomiting over the past 6 months, which occurred after long walks or while performing household chores. These episodes were accompanied by sweating and palpitations. There was no history of headache, tremors, fatigue, weight loss, flushing, anxiety, or constipation. Symptoms would abate with rest. She had previously consulted a doctor and was diagnosed with hypertension and treated with anti-hypertensive medication. An upper gastrointestinal endoscopy showed reflux esophagitis (Los Angeles grade A). She had consulted several other doctors and was prescribed proton pump inhibitors and prokinetics, and her symptoms were attributed to anxiety. She had no other co-morbidities. None of her family members had similar complaints.

Assessment

On arrival at the emergency department, she was in hypovolemic shock, and her vital signs were notable for a pulse rate of 124 beats per minute, a blood pressure of 86/50 mmHg, a respiratory rate of 19 cycles per minute, and a temperature of 37.1 degrees Celsius. Systemic examination was unremarkable.

Laboratory studies at the time of admission showed a hemoglobin level of 11.8 g/dL, a white blood count of 9100 cells/mm 3 (with neutrophils at 53.7%, lymphocytes at 39.5%, and eosinophils at 3.2%) and a platelet count of 375000/mm 3 . Her creatinine level was 0.84 mg/dL. Serum sodium and potassium levels were 139 and 4.6 mEq/L, respectively. Liver function tests were normal, and the arterial blood gas was within normal limits.

Diagnosis

After fluid resuscitation with a 500 mL bolus of 0.9% normal saline, her blood pressure increased to 150/100 mmHg. An abdominal computed tomography scan revealed a well-defined, heterogeneous enhancing lesion measuring 3.9 × 4.1 × 4 cm in the left adrenal gland with areas of cystic degeneration (see Figure 1 A and B). A 24-hour urine test for fractionated metanephrines was elevated at 488 micrograms/24 hours (upper limit 297 micrograms/24 hours), leading to a tentative diagnosis of pheochromocytoma.