A 45‐year‐old woman presented with 5 months of progressive right lumbar back pain radiating to the right abdomen. She denied any history of trauma or neurological symptoms. Associated symptoms included hot flashes, diaphoresis, and constipation. Her medical history was significant for uncontrolled hypertension. Her back had decreased range of motion in the lumbar spine and severe right paravertebral tenderness, but no point tenderness. Abdominal exam revealed a mass 4 cm to the right of the mid‐line and hepatomegaly. Her neurological exam was unremarkable. Abdominal CT showed a 9.5 × 9.5 × 8 cm hypervascular rounded heterogeneous right suprarenal mass. Metaiodobenzylguanide scan identified an area of increased uptake in the same area. The 24‐hour urinary concentrations of dopamine and norepinephrine were 3556 and 228 μg/L, respectively.
Back pain is a common problem encountered by internists. Most patients with back pain lack significant pathology, but histories and physical examinations must screen for red flags. One approach addresses 3 aspects: possible underlying systemic process, neurological compromise, and psychosocial stressors. Cues to an underlying systemic process include the patient's age, history of cancer, unexplained weight loss, intravenous drug abuse, duration of pain, and failed medical management. Neurological involvement may manifest with sciatica, pseudoclaudication, bowel or bladder dysfunction, loss of sensation or strength, or gait abnormalities. Psychosocial distress may lead to pain amplification and prolongation or exhibit as pursuit of secondary gain. Our patient had constant lower right back pain radiating to the abdomen. The pain occurred at night and failed medical management. The results of the abdominal CT confirmed and associated red flags raised the likelihood for underlying systemic pathology.
Catecholamine‐secreting tumors may develop anywhere along the neural crest including paraganglia and the adrenal medullas. The presentation varies widely, from an asymptomatic incidental neoplasm to end‐organ damage secondary to elevated catecholamines. The classic presentation includes episodes of hot flashes, diaphoresis, hypertension, chest pain, dizziness, syncope, or dyspnea. Epinephrine, norepinephrine, and dopamine are inappropriately secreted intermittently, accounting for the episodic nature of the symptoms. A general “rule of 10” has been described for pheochromocytomas: 10% familial, 10% bilateral, 10% malignant, 10% extra‐adrenal, 10% in children, and 10% incidental. Catecholamine‐secreting tumors are rare neoplasms with considerable morbidity and mortality if undiagnosed or untreated. Surgical resection alleviates the symptoms and often reverses the hypertension. Because of the morbidity and mortality associated with delayed diagnosis, physicians must be aware of the classic signs and symptoms of pheochromocytomas in addition to screening for potential red flags in the evaluation of back pain.
T. Turnage ‐ none
To cite this abstract:Turnage T. Raising the Red Flags. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 417. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/raising-the-red-flags/. Accessed April 8, 2020.