Baylor University Medical Center Proceedings July 2017 - 314

Hypertensive crisis secondary to pheochromocytoma
Christopher E. Greenleaf, MD, MBA, Laura A. Griffin, MD, Jay G. Shake, MD, and Wayne S. Orr, MD

Pheochromocytoma is an uncommon tumor of the adrenal glands that can
present with headaches, sweating, palpitations, and paroxysmal hypertension. Pheochromocytoma crisis can lead to cardiomyopathy, pulmonary
edema, and even total circulatory collapse. We describe a patient with
hypoxic respiratory failure requiring extracorporeal membrane oxygenation
to stabilize until the pheochromocytoma was discovered and treated.

heochromocytoma is an uncommon tumor of the adrenal
glands that can present with headaches, sweating, palpitations, and paroxysmal hypertension (1). Surgical excision
is the only curative option. Preoperative management
includes alpha blockade and volume expansion followed by beta
blockade to treat tachycardia after suﬃcient alpha blockade has
been established in order to prevent pheochromocytoma crisis.
This crisis can usually be prevented if the pheochromocytoma
is known, but sometimes this hypertensive crisis is the initial
manifestation of the disorder. A crisis can lead to cardiomyopathy, pulmonary edema, and even total circulatory collapse (2).
We describe a patient with hypoxic respiratory failure requiring
extracorporeal membrane oxygenation (ECMO) to stabilize until
the pheochromocytoma was discovered and treated.
CASE REPORT
A 37-year-old woman initially presented to an outside
hospital with a chief complaint of nausea, vomiting, and abdominal pain. In the emergency department waiting room, she
had a syncopal episode and was found to have a pulse oximeter oxygen saturation of 80% and hypertension with a blood
pressure of 200/100 mm Hg. She was intubated because her
hypoxia could not be improved with noninvasive methods and
was then transferred to our tertiary medical center. Upon admission, an arterial blood gas showed a pH of 6.8, partial pressure of carbon dioxide of 51, partial pressure of oxygen of 71,
and lactate of 10 mmoL/L. She had progressively worsening
oxygenation and ventilation despite increasing ventilatory support. Neuromuscular-blocking agents and multiple ventilator
modes and maneuvers including airway pressure release ventilation were unsuccessful in improving her respiratory status.
Her initial chest radiograph is shown in Figure 1. During this
time she also had extreme blood pressure lability with systolic
314

Figure 1. Chest radiograph on the day of admission.

pressures ranging from 80 to 200 mm Hg. Because she could
not be adequately ventilated and oxygenated, the cardiothoracic surgical service was consulted. The patient was placed on
veno-venous ECMO with a 23Fr femoral venous cannula and a
21Fr right internal jugular venous cannula. While stabilized on
veno-venous ECMO, ventilation, oxygenation, and metabolic
acidosis improved over the next few days.
Her family disclosed that the patient had a long history of
refractory hypertension with failed medical management, intermittent headaches, and palpitations. The family also reported that
the patient had not taken any of her blood pressure medications
during the 2 weeks prior to her presentation because she could
no longer aﬀord them. Computed tomography angiography of
the chest, abdomen, and pelvis showed bilateral, diﬀuse areas
of ground glass opacity in the lung parenchyma and a large left
From the Department of Surgery, University of Mississippi Medical Center,
Jackson, Mississippi.
Corresponding author: Christopher Greenleaf, MD, MBA, Department of Surgery,
University of Mississippi Medical Center, 2500 North State Street, Room S376,
Jackson, MS 39216 (e-mail: cgreenleaf@umc.edu).
Proc (Bayl Univ Med Cent) 2017;30(3):314-315

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