Complex hemodynamic changes induced by pheochromocytoma may lead to adrenergic shock. Accidental discovery of adrenal mass may be a first step in diagnosis. However, clinical significance of adrenal mass in critically ill patients is unclear because adrenal incidentalomas are common and frequently clinically silent.
Retrospective analysis of patient reports. Abstracted data included patients’ demographics, medical history, clinical presentation, imaging results, hemodynamic parameters and pathology findings.
We identified 47 reports of patients with pheochromocytoma-associated shock between 1966 and 2003. Mean patients’ age was 44 (SD ±13) years. Sixty-eight percent were females. Only 23% of patients had previously documented hypertension. Minor abdominal trauma was possibly associated with shock in two patients. Drugs such as metoclopramide, phenothiazines, imipramine, beta-blockers, amiodarone and marijuana were used in 30 % of patients shortly before shock developed. Abdominal imaging (CT, MRI, and ultrasound) first identified pheochromocytoma in 83 % of the patient in adrenergic shock diagnosed after 1980. In 23% of patients, diagnosis of pheochromocytoma was only made at autopsy. Average diameter of pheochromocytoma in patients with adrenergic shock was 7 cm (SD±3). Central necrosis and/or hemorrhage were present in 78% of patients. Despite a common belief, hypotension was associated with predominantly adrenaline secreting pheochromocytomas (epinephrine/norepinephrine > 1) in only 6 out of 20 patients (30%). Mortality of adrenergic shock in this case series was 32%.CONCLUSIONS: In patients who develop adrenergic shock, pheochromocytoma is not suspected and is usually incidentally found by abdominal imaging. Adrenergic shock may be initiated by drugs and minor abdominal trauma. Adrenergic shock is associated with large pheochromocytomas with central necrosis and/or hemorrhage. Adrenergic shock is seen both in noradrenaline and adrenaline secreting tumors.
Finding of a large adrenal mass with central necrosis and/or hemorrhage in critically ill patient should prompt rapid biochemical confirmation of pheochromocytoma. Emergent surgical removal of pheochromocytoma should be considered given the high mortality associated with adrenergic shock.
B. Schifferdecker, None.