S. Tadic 1 , J. Hefner 1 ; 1 University of Pittsburgh, Pittsburgh, PA (Tracking ID #76487) LEARNING OBJECTIVES: 1.) Recognize an unusual presentation of a hypertensive emergency in a young person; 2.) Diagnose an atypical presentation of a pheochromocytoma; 3.) Evaluate and treat a catecholamine-producing tumor. CASE INFORMATION: A previously healthy 27-year-old Vietnamese male was brought to the emergency room with an acute onset of an expressive aphasia and left hemiparesis. He was unresponsive upon arrival and required intubation. A head CT revealed a large subcortical intracranial hemorrhage (ICH) involving the right basal ganglia. The patient underwent an emergent right craniotomy with evacuation of the intracerebral hemorrhage and placement of an extraventricular drain. Postoperatively, he was admitted to the Neuro Intensive Care Unit (NICU) for monitoring. Over the next 72 hours the patient was observed by nursing staff to have periods of intermittent hypertension, treated with prn IV medications and hypotension, treated with fluid boluses (SBP range 88±210). After 4 days in the NICU, the patient was observed to have facial and chest flushing. A pheochromocytoma was suspected. Abdominal MRI revealed bilateral large adrenal masses with increased T2-weighted signal. Results of a 24hour urine collection for metanephrines and catecholamines included: metanephrines 6,320 (26±230 mcg/24 hr); normetanephrines 24,760 (44±540 mcg/24 hr); VMA 16.5 (6 or less mg/ 24 hr); and total metanephrines 31,080 (90±690 mcg/24 hr). Urine dopamine 2,136 (80±440 mcg/24 hr); epinephrine 423 (0±25) and norepinephrine 3,071 (0±100). Calcitonin level was 5 (0-8) and genetic testing for von Hippel-Lindau (vHL) syndrome was negative. The patient developed a right femoral DVT and tested positive for the Lupus Anticoagulant. He underwent a bilateral adrenalectomy and was discharged to home 2 months later on Coumadin and Hydrocortisone. Pathology revealed malignant pheochromocytoma and a metastatic workup was negative. His post-surgical evaluation revealed normal levels of urine metanephrines and catecholamines. IMPLICATIONS/DISCUSSION: Although pheochromocytoma is a rare disease, this case represents the value of bedside evaluation by a physician. Paroxysmal symptoms (i.e. intermittent) can often be treated with prn interventions leading to misdiagnosis or delay in diagnosis. A rare presentation of pheochromocytoma is one of cyclic fluctuations of HTN and hypotension that occurs via an uncertain mechanism. While most pheochromocytomas are sporadic, bilateral tumors are often associated with 2 primary familial disorders: MEN-2 and VHL. Measurement of plasma or urine catecholamines and metabolites are diagnostic in 95% of patients with symptoms. MRI scans are sensitive (98±100%) but are only 70% specific. On T2-weighted images, however, pheochromocytomas appear hyperintense while other adrenal tumors appear isointense. While there is no universally accepted method of preparation for surgery, alpha-adrenergic blockade followed by beta-blockers with surgery 2 weeks later, is common practice. Recurrence rates are 14% at 10 years. LEARNING OBJECTIVES: This clinical vignette discusses the ethical implications of using medication and housing contracts in voluntary case management programs. The Medical High User Case Management Program provides intensive case management, assisting patients with medical adherence, entitlements and housing. When appropriate, case managers will draft housing and medication contracts for opiate pain medications Contracts are done in consultation with primary care providers and the program internist psychiatrist and nurse.