SAT-214 Steroid Induced Pheochromocytoma Crisis

BACKGROUND: The factors triggering adrenergic crisis in pheochromocytoma are most often related to induction during anesthesia or manipulation of tumor during surgery. A variety of drugs have also been reported to be associated with adrenergic crisis, however there are only scarce case reports on pheochromocytoma crisis induced by steroids. Here we present a case of steroid induced pheochromocytoma crisis. Clinical Case: 58 year-old female with history controlled hypertension on Lisinopril 10 mg daily, presented to hospital with two day history of fatigue, shortness of breath, and abdominal pain. A CT chest and abdomen showed emphysema and an indeterminate right adrenal gland nodule. Due to patient symptoms and findings of emphysema patient was started on Prednisone 40 mg daily. Home Lisinopril was restarted and patient was placed on sodium restriction. Ten hours after the start of prednisone the patient developed sudden onset hypertension with BP >200/100 mmHg for which she was given labetalol intravenously. The patient developed orthostatic hypotension hours after with BP readings as low as 50s/40s. Due to labile BP a work-up for adrenal adenoma was started. Plasma and urine metanephrines and noremetanephrines returned 7–11 times and 4–15 times above upper limit of normal (ULN) respectively. Plasma and urine metanephrines were repeated when patient was off steroids and normotensive and still returned abnormally high (about 2–3 times ULN) along with elevated urine catecholamines (epinephrine 6.5 times ULN and with only a slight elevation in norephinephrine and normal dopamine levels). A dedicated adrenal scan showed a 2.2 cm right adrenal mass with homogeneous enhancement, 130 HU, with an absolute and relative washout of 65% and 44% respectively, not consistent with a benign adenoma. Patient was placed on a high salt diet along with fluids and doxasozin. Once appropriately alpha blocked, metoprolol was added prior to surgery. Clinical lessons: In the setting of labile BP, one should keep a high clinical suspicion for pheochromocytoma. Orthostatic hypotension here was related to epinephrine predominance pattern of secretion and volume depletion. Steroids should be avoided in patients with known pheochromocytoma or in those with an adrenal adenoma without a negative biochemical workup for a pheochromocytoma as it could precipitate an adrenergic crisis possibly by inducing catecholamine synthesis and release and sensitizing target organs to the effects of catecholamines. Reference: 1. Rosas AL, et al. Pheochromocytoma crisis induced by glucocorticoids: a report of four cases and review of the literature. European Journal of Endocrinology (2008) 158 423–429.