INTERNATIONAL JOURNAL OF CLINICAL AND MEDICAL CASES (ISSN:2517-7346)

A 28-year-old female G1P1001 presented to the family medicine clinic to establish care and for management of hypertension 6 months after a C-section delivery at 36 weeks. Her pregnancy was complicated by chronic hypertension which evolved into superimposed pre-eclampsia with severe features. She noted that prior to pregnancy her hypertension was well controlled on metoprolol, but during pregnancy she was placed on labetolol, and then replaced with nifedipine, and her blood pressure was still frequently above 140/90 with symptoms of “shakiness” when her blood pressure would rise. Physical examination at this visit, aside from a blood pressure of 145/96, was unremarkable. Family history was remarkable for cardiovascular disease, specifically hypertension and heart failure. Social history was unremarkable for tobacco use, alcohol use, and illicit drug use. Labs at this visit, including CBC, CMP and lipids, were unremarkable. She was placed back on metoprolol, and her blood pressure did well for about 1 month.

She then presented to clinic with episodes or “spikes” of hypertension described as a persisting constellation of symptoms lasting five to ten minutes, which included a drop in her heart rate followed by increased blood pressure accompanied by shortness of breath, intense palpitations, dizziness, and chest pain. These were precipitated by no known cause and resolved without any specific treatment. She did not feel anxious prior to these episodes, and the episodes would occur three to five times per day. Following this visit, she was switched to amlodipine, however she developed a rash and was placed back on metoprolol with clonidine to use as needed for treating her “spikes” of high blood pressure.

At this time, further testing was initiated, and a referral to cardiology was generated. 

EKG revealed normal sinus rhythm with sinus arrhythmia.

A Holter monitor showed sinus rhythm with very rare premature supraventricular beats and an average heart rate of 82 bpm. Reported symptoms (weakness, fatigue, lightheadedness, shortness of breath, tingling) correlated with normal sinus rhythm.

Zio Patch monitoring was negative for significant arrhythmia, with average HR 79, and one 4 beat SVT run at 150s bpm.

Transthoracic Echo performed was normal and unremarkable.

Renal ultrasound with doppler was performed and showed no evidence of renal artery stenosis and unremarkable kidneys. There was, however, an incidental finding of an apparent 4 cm complex abnormality in the mid abdomen slightly to the left of the aorta, for which CT correlation was suggested (Figure 1).

CT Abdomen & Pelvis with and without IV contrast showed an indeterminate 4.3 cm heterogeneously enhancing partially cystic left adrenal mass (Figure 2).

Laboratory tests performed included urine and blood catecholamines and metanephrines (Table 1).

Subsequent MRI Renal with and without IV contrast showed a left suprarenal 4.5 cm complex solid and cystic lesion compatible with an adrenal versus extra-adrenal cystic pheochromocytoma (Figure 3,4).