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Pheochromocytoma and papillary carcinoma in a man with hypertension and acute cholecystitis.

Article Excerpt
A 77-year-old man of Japanese ancestry with a history of well-controlled hypertension was seen in the morning for a routine examination. His blood pressure was normal as were the results of a complete blood cell count and liver function tests. About 6 hours later, he presented to the emergency department with acute abdominal pain accompanied by nausea, vomiting, fever, and chills. He denied headaches, palpitations, and diaphoresis.

On admission, his blood pressure was 220/100 mm Hg. He had right upper quadrant tenderness. An ultra-sonogram and CT scan of the abdomen revealed acute cholecystitis with stones in the common duct and an incidental 5 x 6-cm left para-aortic mass (Figure 1). The patient underwent endoscopic retrograde cholangiopancreatography, during which his systolic blood pressure was difficult to control and fluctuated widely.

The following urinary levels were elevated: vanillylmandelic acid (VMA) (17.2 mg/24 h; normal, less than 6 mg/24 h), norepinephrine (445 [micro]g/24 h; normal, 15 to 100 [micro]g/24 h), and normetanephrine (more than 3528 [micro]g/24 h; normal, 122 to 676 [micro]g/24 h); plasma norepinephrine was also elevated (2649 pg/ mL; normal, 112 to 658 pg/mL). These findings were consistent with a paraganglioma.

[FIGURE 1 OMITTED]

A metaiodobenzylguanidine (MIBG) scan showed uptake isolated to the para-aortic mass. Further workup included a chest CT scan that revealed a left thyroid mass. Fine needle aspiration biopsy findings were consistent with papillary carcinoma. CT and MRI scans of the brain showed left anterior middle cranial fossa tumors and right frontal tumors, consistent with meningiomas. Intact parathyroid hormone level was elevated (100 pg/mL; normal, 10 to 65 pg/mL). Levels of serum...