A 55-year-old white woman with a medical history notable for thyroid cancer (managed with thyroidectomy), subsequent hypothyroidism, and hypertension presented to the emergency department with acute symptoms of chest pain, nausea, and dizziness. The patient was diaphoretic and hypotensive, which improved after fluid resuscitation. She denied headache, palpitations, and shortness of breath. Her systolic blood pressure (mm Hg) was in the 90s, but all other vital signs were stable. Results of laboratory studies revealed elevated D-dimer of 531 ng/mL (reference range, <500 ng/mL) and elevated troponin of 2.65 ng/mL (reference range, <0.02 ng/mL). An electrocardiogram did not show any acute ST-T wave changes. With the presumed diagnosis of non–ST-segment elevation myocardial infarction, she was transferred for higher level of care. While at the tertiary medical center, she continued to have persistent chest discomfort despite administration of 0.4 mg of sublingual nitroglycerin and 4 mg of morphine. Troponin levels remained elevated. The patient was taken for cardiac catheterization with possible revascularization. An angiogram revealed anterobasal and anterolateral akinesis with an ejection fraction of 35% to 40%. No evidence of coronary artery disease was found and no intervention was indicated. Her symptoms improved, and she was discharged from the hospital 2 days after presentation with recommendation for routine follow-up.
Seven days after hospital discharge, the patient presented to the emergency department again with symptoms of atypical chest pain with associated nausea and diaphoresis. In addition, she reported shortness of breath, headache, and blurry vision. Physical examination revealed elevated blood pressure and occasional tachycardia, but all other findings were benign. Chest radiograph showed perihilar and lower base opacities suggestive of pulmonary edema and pulmonary congestion. With these additional symptoms and findings, computed tomography of the abdomen was ordered, the results of which revealed an 8.5-cm solid ovoid mass in the right adrenal gland (
Figure). Laboratory data revealed a plasma metanephrine level of 247 pg/mL (reference range, 0-62 pg/mL); plasma normetanephrine, 1710 pg/mL (reference range, 0-145 pg/mL); urinary metanephrine, 852 μg/24 h (reference range, 45-290 μg/24 h); and 24-hour urine normetanephrine, 2916 μg/24 h (reference range, 82-500 μg/24 h). With evidence of biochemical pheochromocytoma and a right adrenal mass, she was referred to a surgeon for resection and discharged from the hospital. In the interim, she began phenoxybenzamine therapy (10 mg twice daily), which was well tolerated. After 3 days, a β blocker (metoprolol, 12.5 mg daily) was added to better control her tachycardia. One week after her second presentation to the emergency department, the adrenal mass was surgically removed and the patient had an uneventful recovery. Repeated echocardiogram 1 month after surgery showed resolution of all wall motion abnormalities and preserved left ventricular ejection fraction. Her hypertension also resolved and her blood pressure medications were discontinued.