Pheochromocytoma crisis is defined as an acute severe presentation of catecholamine-induced haemodynamic instability, causing end organ damage or dysfunction. Difficulty on diagnosing this syndrome in Emergency Department (ED) leads to delay in management which is associated with significant mortality.
A 34-year-old lady presented to ED with 2 weeks history of high grade fever, generalised body weakness, reduced oral intake and abdominal pain. She was well prior to this illness. Clinically, she was dehydrated, drowsy and tachypneic. Blood pressure was recorded as 192/128mmHg with heart rate of 167 beats/ minute and core body temperature of 42.1 degree celcius.Other examinations were unremarkable. Bedside focused cardiac ultrasound (FCU) showed hyperdynamic heart with collapsed inferior vena cava (IVC). She has been resuscitated using external and internal cooling method prior to intubation. Broad spectrum antibiotic was administered. The laboratory data showed raised white blood cell, features of acute kidney injury and lactate of 4.47 mmol/L. Urine toxicology screening and thyroid function were normal. Bedside abdominal ultrasound was performed and revealed a large lobulated mass at left suprarenal region measuring 8 x 13 cm.
Diagnosis of Pheochromocytoma crisis was made. Patient’s condition worsened and she persistently anuric before she developed hypotension and cardiac arrest. She was pronounced death 3 hours after her presentation and postmortem finding has confirmed the diagnosis.
Discussion and Conclusion
Pheochromocytoma crisis consists of a constellation of symptoms resemble other life threatening condition. It is difficult to diagnose if the patient not known to have pheochromocytoma. It can be mistreated as sepsis, thyroid storm and malignant hyperthermia. The usage of ultrasound in emergency department carries significant impact in term of early diagnosis and management of unstable, critically ill patient.
pheochromocytoma, endocrine emergency, hyperthermia