A Rare Case Report of Extra-adrenal Pheochromocytoma with Normal Blood Pressure: Is that Possible?

Extra-adrenal pheochromocytoma is uncommon and usually secreting nor-epinephrine. We are presenting a possible case of extra-adrenal pheochromocytoma in a 68-year-old male who was admitted to Queens Hospital Center complaining of shortness of breath for two days. Physical examination was unremarkable except tachycardia. Ventilation/perfusion (V/Q) scan showed the intermediate probability for pulmonary thromboembolism. Computed tomography (CT) chest confirmed the presence of old embolism and showed the 1.1 cm nodule in the left upper lobe. He suddenly collapsed and went into cardio-respiratory failure and attempts to resuscitate were futile. Results for pheochromocytoma workup received after the patient has passed away and it showed elevated levels of 24-hour urine metanephrine, normetanephrine, and Vanillylmandelic acid (VMA). In our patient, CT abdomen did not identify any mass in the adrenal gland or at the bifurcation of the aorta. The extra-adrenal tumor can secrete enough epinephrine to negate the hypertensive effect of norepinephrine. The clinician should be aware of the possibility that tachycardia could be a presenting symptom in pheochromocytoma although the patient is normotensive.