A 40‐year‐old man without any medical history presented to the emergency department with sudden onset of severe substernal chest pain. He described it as nonradiating, sharp, cramping, and constant. It was associated with palpitations, high‐grade fevers, and nausea and vomiting. He denied shortness of breath, back pai,n or cough. Family history was positive for diabetes and coronary artery disease. Patient had a remote smoking history of approximately 2 pack‐years and he denied any alcohol or illicit drug use. Admission vitals were pulse 109 bpm, blood pressure 222/98 mm Hg, temperature 99.9°F and saturating 97% on room air. On physical exam he was slightly diaphoretic and pale without any respiratory distress. Initial labs were remarkable for elevated leukocytosis, moderately elevated blood glucose, anion gap metabolic acidosis and urinalysis positive for ketones. Cardiac enzymes were negative. Continuous insulin infusion and aggressive intravenous fluids were started for diabetic ketoacidosis. Chest x‐ray was negative for acute cardiopulmonary process, and EKG showed sinus tachycardia with nonspecific ST changes. CT angiogram of the chest was negative for pulmonary embolism or aortic dissection, but did demonstrate a large mass in the right suprarenal fossa. Approximately 8 hours later the patient developed hypoxic respiratory failure requiring BIPAP. Repeat labs showed worsening renal function and elevation of cardiac enzymes. He was placed on acute coronary syndrome protocol for non‐ST‐elevation myocardial infarction. Because of high suspicion for pheochromocytoma based on adrenal mass on CT scan, blood pressure was controlled with nicardipine and phenoxybenzamine. Beta‐blockade was initiated 2 days later. Diagnosis of pheochromocytoma was confirmed with total plasma metanephrines > 20,000 and plasma normetanephrines > 12,000.
Pheochromocytoma has been known as the “great mimic” and often times is a diagnostic challenge given its rarity. Symptoms like palpitations, sweating, and fever are quite nonspecific, especially in the setting of diabetic ketoacidosis and acute myocardial infarction. Although stress hyperglycemia and glycosuria have been shown to be associated with catecholamine excess, our patient presented with diabetic ketoacidosis which is an extremely rare initial presentation of pheochromocytoma.
Pheochromocytoma is a rare catecholamine‐producing neuroendocrine tumor that usually arises from the adrenal medulla. Its common presentation involves paroxysmal hypertension, palpitations, headaches and diaphoresis. Only 0.05% to 0.1% of patients with sustained hypertension are found to have pheochromocytoma. Organ ischemia, such as stroke, myocardial infarction, arrhythmias are less common, and depend on the amount of catecholamines released. We present a case of a middle aged male with diabetic ketoacidosis as the initial presentation of this tumor.
To cite this abstract:Gill P, Gohar S, Lustig M. Diabetic Ketoacidosis — Could Be a Pheochromocytoma!. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 398. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/diabetic-ketoacidosis-could-be-a-pheochromocytoma/. Accessed July 23, 2019.