A 51-year-old man comes to the emergency department with complaints of palpitations

[Oak]

A 51-year-old man comes to the emergency department with complaints of palpitations, sweating, headache, nausea, and vomiting that began several hours previously. In the emergency department, his blood pressure is noted to be 180/135 mm Hg and his heart rate is 115/min. No fever is present. The lungs are clear to auscultation. Stat complete blood count is within normal limits. The patient's blood pressure is controlled with a combination of alpha and beta blockers. 24-hour urine is then collected, which shows markedly increased levels of vanillylmandelic acid (VMA) and homovanillic acid (HVA). Which of the following is the most likely diagnosis?

A. Addison disease
B. Graves disease
C. Pheochromocytoma
D. Thyroid adenoma
E. Thyroid carcinoma

[bharat]

Originally Posted by Oak

A 51-year-old man comes to the emergency department with complaints of palpitations, sweating, headache, nausea, and vomiting that began several hours previously. In the emergency department, his blood pressure is noted to be 180/135 mm Hg and his heart rate is 115/min. No fever is present. The lungs are clear to auscultation. Stat complete blood count is within normal limits. The patient's blood pressure is controlled with a combination of alpha and beta blockers. 24-hour urine is then collected, which shows markedly increased levels of vanillylmandelic acid (VMA) and homovanillic acid (HVA). Which of the following is the most likely diagnosis?

A. Addison disease
B. Graves disease
C. Pheochromocytoma
D. Thyroid adenoma
E. Thyroid carcinoma

I think this is the case of Pheochromocytoma because patient had symptoms like "complaints of palpitations, sweating, headache, nausea, and vomiting that began several hours previously.
well he has hypertension and
vanillymandelic acid are elevated in the pheochromocytoma
well i think i have posted one mcq before regarding neuroblastoma.
well bro . but i still don't know Vanillylmandelic acid (VMA) and homovanillic acid (HVA) haru kun kun condition ma increase hunceh please yeaslai pani focus garnu hola hai taepai ko reply ma
well i will go for C. Pheochromocytoma

[Oak]

Thats right bharat the correct answer is C. The patient most likely has a pheochromocytoma. These tumors are proliferations of catecholamine-secreting chromaffin cells, and can be found in the adrenal medulla (80% of cases) or in extra-adrenal sites derived from neural crest, including the paraganglia of the sympathetic chain, along the aorta, in the carotid body, in the genitourinary system, and in the brain. About 10% of the adrenal tumors are bilateral. 5% of adrenal and 30% of extra-adrenal pheochromocytomas are malignant. The tumors can present with paroxysmal (as in this case) or persistent hypertension, or may rarely be clinically silent. The diagnosis is established by demonstrating urinary metabolic products of epinephrine and norepinephrine, most commonly vanillylmandelic acid and homovanillic acid. Surgical resection is the preferred treatment.

Addison disease (choice A) causes adrenal cortical hypofunction, and is a cause of decreased blood pressure with orthostatic hypotension.

Hyperthyroidism due to Graves disease (choice B), thyroid adenoma (choice D), or thyroid cancer (choice E) often causes tachycardia and may cause hypertension (particularly with widened pulse pressures), but would not cause increased urinary secretion of metabolic products of epinephrine and norepinephrine.

[Oak]

Originally Posted by bharat

well bro . but i still don't know Vanillylmandelic acid (VMA) and homovanillic acid (HVA) haru kun kun condition ma increase hunceh please yeaslai pani focus garnu hola hai taepai ko reply ma
well i will go for C. Pheochromocytoma

This test is primarily used to diagnose pheochromocytoma and neuroblastoma, and to monitor the effectiveness of their treatments.

Certain foods can increase urinary catecholamines, like

coffee
tea
bananas
chocolate
cocoa
citrus fruits
vanilla.

This type of food contents must be avoided several days prior to the test.


Acute stress and vigorous exercise may also affect the test results. The following drugs can increase catecholamine measurements:

caffeine
acetominophen (Tylenol)
levodopa
lithium
aminophylline
chloral hydrate
clonidine
disulfiram
erythromycin
insulin
methenamine
methyldopa
nicotinic acid (large doses)
quinidine
tetracyclines
nitroglycerin

Drugs that can decrease catecholamine measurements include:

clonidine
disulfiram
guanethidine
imipramine
MAO inhibitors
phenothiazines
salicylates
reserpine

Elevated levels of urinary catecholamines may indicate:

acute anxiety
ganglioblastoma (very rare)
ganglioneuroma (very rare)
neuroblastoma (rare)
pheochromocytoma (rare)
severe stress

[Hero]

Pheochromocytoma is also known as disease of 10. But, I would rather like to say it is a disease of 90. Coz,
90% are benign, 10 % malignant,
90% are in adrenal medulla, 10% are extra-adrenal
90% are unilateral, 10% are bilateral
90% can be cured by surgery.
Bharat has raised a very good question. False positive biochemical test results for phaeochromocytoma are common. Oak has nicely mentioned the causes for false + and false -ve lab results. Actually many cases of pheochromocytoma are diagnosed only on autopsy. That's why I think clinical findings are more useful for the dx of this disease. Persistent or Paroxysmal HTN, palpitation, perspiration, pallor (4P) are the most common features.

[Oak]

Hero, very optimistic view with 90%, I also read the disease of 10% never thought that way its cool

[situ]

hi still i m not getting u ppl what actually we can do here ......i found its like discussion on class with teacher isn't it?n next whoever have put question he must know it or not ?

[Alpine]

Originally Posted by situ

hi still i m not getting u ppl what actually we can do here ......i found its like discussion on class with teacher isn't it?n next whoever have put question he must know it or not ?

situ, actully this section is about the multiple choice question, although i rarely take part in the discusion say i rarely answer but I keep reading this section.

all of them are very much expert, and they do discuss when there is doubht thats all about it. don't worry just go through all the contents you will get it

[Love Nepal]

very good discussion guys.
At whatever level of our quest to learn medicine, we all would benifit from these discussions.
Pheochromocytoma is a rare cause of secondary hypertension,there are commoner ones and discussion on them would also be very fruitful.
So guys lets begin,from the commonest one...........

[UnKnown]

Good job guys for such a good discussion.
the answer is straight foreward Pheochromocytoma.
The only thing i want to add is you dont treat HTN in them with beta blockers first because there will be excessive alpha blockade and exacerbation of HTN.