Incidental Giant Cystic Phaeochromocytoma: A Case Report

Background: This case report describes a large sporadic benign phaeochromocytoma with classic symptoms and an unexpected SARS-CoV-2 virus contagious during the first pandemic wave. Clinical Case: A 61-years-old healthy man was admitted in the hospital emergency with hypertension, facial flushing, headache, nausea, vomiting and tremors. The patient presented hypertensive encephalopathy requiring orotracheal intubation. During the procedure, after rocuronium administration, the arterial pressure levels suddenly incresead more. An abdomen CT performed for vomiting investigation showed a mass in the left upper quadrant measuring 12.3 x 8.1 x 11.4 cm, central cystic area and sparse coarse calcifications, solid component density of 30 UH in the non-contrast phase and absolut washout of 48%, suggesting phaeochromocytoma (FEO) etiology. The patient renal function impaired and hemodialysis was required as replacement therapy. Even with small amount of urine available for exams, 24h urine tests were compatible with FEO diagnosis: (normetanephrines above 4260 mcg/L, n< 732 mcg/L, 250 mL of urine). Considering the severity of symptoms, a chest CT scan was provided, not demonstrating any metastatic disease. Parenteral antihypertensive medication to manage blood pressure was required and this withdraw was reached after the introduction of prazosin 2 mg twice a day. After adequate preoperative preparation, the surgical removal was performed. Systolic BP intraoperative fluctuations occurred, with variations between 70 and 210mmHg. Splenectomy was necessary due the intimate contact with the adrenal mass. No obvious metastases were observed. The anatomopathological showed a 390 grams adrenal mass confirming FEO (PASS score 5). Genetic panel for phaeochromocytoma and paraganglioma with complete sequencing found no pathogenic variants in any of the 22 genes analyzed, suggesting sporadic etiology. The patient got infected with COVID-19 after a family visitor confirmed by molecular test. He developed mild respiratory symptoms, delaying his hospital discharge. He was released seven weeks after surgery with complete kidney recover function using low doses of prazosin. Plasma metanephrines and normetanephrines were normal. Conclusion: Phaeochromocytoma is a rare disease with no specific clinical signs and symptoms. It implies in potentially lethal cardiovascular complications, especially during the COVID-19 pandemic. On the other hand it is a curable illness through the surgical tumor removal. Attention should be paid to high blood pressure levels even after the tumor is removed which can be justified by the remaining vascular hypertrophy as long as the suspicion of malignant FEO is excluded.