Adrenal Mass Hemorrhage Clinically Mimicking a Pheochromocytoma

Background: A pheochromocytoma is diagnosed clinically using correlation of clinical, imaging, and laboratory studies. We report the case of an adrenal mass hemorrhage that presented with significantly elevated urine metanephrines mimicking a pheochromocytoma. Clinical Case: A 59-year-old healthy woman presented to the ED with chest pain, left flank and upper quadrant pain associated with diaphoresis and palpitations. Vital signs were significant for a pulse of 92 bpm, and a BP of 213/88 mm Hg. Physical exam revealed tenderness to palpation on the left upper quadrant and left costovertebral angle. Laboratory tests were significant for an elevated D-dimer (2,449 ng/mL, reference range 215–499 ng/mL). CT abdomen with IV contrast showed a 3.5 x 2.9 cm round mass abutting the lateral limb of the left adrenal gland with surrounding fat stranding with suspicion of inflammation or hemorrhage. 24-hour urine metanephrines showed elevated metanephrine (7,227 mcg/24hr; reference range <400 mcg/24 hr) and normetanephrine (1,209 mcg/24hr; reference range 900 mcg/24 hr). In the setting of up trending cardiac enzymes and inferior-lateral ST segment depression, a cardiac catheterization was performed which was unrevealing. She was discharged from the hospital and referred to endocrinology. On that visit, ~ 1 month after the patient was admitted to the hospital, plasma metanephrines were ordered which showed mildly elevated plasma metanephrine (0.83 nmol/L; reference range <0.5 nmol/L) and normetanephrine (1.2 nmol/L; reference ranges <0.9 nmol/L). An MRI abdomen with and without contrast revealed a 2.7 x 2.2 x 1.8 cm nodule arising from the lateral limb, with loss of signal on in-phase images suggestive of blood products. Plasma metanephrines and MRI findings ruled out the diagnosis of a pheochromocytoma. Conclusion: To our knowledge, few cases of an adrenal mass hemorrhage clinically mimicking a pheochromocytoma have been reported. Although the inpatient clinical presentation of our patient was consistent with this, the outpatient plasma metanephrines and MRI were not. An adrenal adenoma hemorrhage should be considered as a potential differential diagnosis for elevated metanephrines, which can clinically mimick a pheochromocytoma. References: (1)Sekos K, Short T, Ing SW. Adrenal hemorrhage due to hypercoagulable state mimicking pheochromocytoma. Journal of Clinical and Translational Endocrinology: Case Report. 8. 9–12. 2018.(2)Wordsworth S, Thomas B, Agarwal N, Hoddell K, Davies S. Elevated urinary cathecholamines and adrenal haemorrhage mimicking phaechromocytoma. BMJ Case Reports. 2010.