1. CC
Pt is a 48 yo AA male who presents with SOB.

2. HPI
SOB has been progressive over the last couple of weeks. Patient has had orthopnea, no dyspnea on exertion, cough productive of white sputum. Patient denies fever,admits wheezing, denies pedal edema, denies palpitations, denies chest pain or pressure.

3. PMHx
Pt has had 16 year Hx of HTN, refractory to multiple medications including, Ace-I, HCTZ, BB and CCB.
BPH

4. FHx
Diabetes in Father
Father died of MI

5. SHx Patient has a Hx of cocaine use that ended 2 years ago.
Patient currently smokes 1 ppd

6. ROS Claims weight loss of 10 lbs over 1 month
Constipation for 2 weeks, only broken miralax, several days ago

7. Medications and Allergies
Clonidine
Metoprolol
HCTZ
Amlodipine
PCN-allergy of rash

8. PE Afebrile, HR 111, BP 203/139, RR 18, SAO2 99% on RA
A large non-obese AA man AAOX3
Coughing, speaking complete sentences, in NAD, mild dyspnea on minimal exertion
No visible JVD, no pedal edema,
Taccycardic s1s2, with s4 gallop, no murmur, no rub
Good inspiratory effort with reduced breath sounds on posterior lung fields, no crackles

9. Labs Na-134 K-3.9 Cl-95 CO2-23 BUN-13 Cr-1.1 Glu-103 BNP-4054
WBC-12.4 Hg-11.7 Hct-33.8 Plat-287
Troponin=0.06, CKMB=9.0, CK=522
CT chest- no PE, b/l pleural effusions, L heterogenous mass w/ internal calcification from adrenal gland

10. SHOW IMAGE

11. Differential?

12. Essential Hypertension
Renal Cell Carcinoma
Cocaine induced HTN
Thyrotoxicosis
Systolic CHF
Diastolic CHF
COPD exacerbation
Pheochromocytoma
Post-renal ARF with fluid overload

13. Pheochromocytoma
Definition: a catecholamine secreting tumor derived from chromaffin cells in adrenal medulla.

14. Epidemiology: no gender difference, 0
Epidemiology: no gender difference, 0.05% of population, incidence at is highest at yo.
Associated with MEN II: Medullary carcinoma, 1 Hyperparathroidism, Pheochromocytoma, (RET gene)
Associated with Von Hippel Lindau-hemangioblastomas (CNS), retinal angiomas, renal cysts, clear cell renal carcinoma, pancreatic cysts, papillary cystadenoma of epididymus, endolymphatic sac tumors (Von Hippel Lindau gene)

15. Symptoms: hypertension 55%, headache 80%, palpitations 70%, hyperhydrosis 60%
Signs of heart failure, high BP, sinus taccycardia s4 gallop, pulmonary edema, MR, LVH w/ lateral PMI.

16. 24 hour collection for metanephrines:
100% sensitive
Patient’s: Normetanephrine 20,154 (649)
Metanephrine 105 (203)
Total Metanephrine 20,259 (739)
Plasma [normetanephrine>2.5 pmol/ml] or [metanephrine>1.4 pmol/ml]
100% specific
We decided to wait for biopsy, also 100% specific

17. Scintigraphy w/ 131 I-MIBG (NE analog) targets to adrenergic tissue
Clonidine suppression test- clonidine should no suppress the plasma levels of NE

18. Treatment requires phenoxybenzamine, B blocker, metyrosine and IV rehydration 14 days prior to surgery
Surgical Resection

19. Cardiac Reflections
Echo 3/2: LV diastolic dysfunction, EF45-49%, LV relaxation abnormality.
Techitium 99 M Stress test 3/4: LVEF estimated at 29%, global hypokinesis, and inhomogenous trace uptake, compatible with dilated cardiomyopathy.
Cardiac Catheterization: moderately severe RCA 70%, LV 30%