Sars-Cov-2 Infection as Catecholamin Crisis in Pheocreomocitoma: A Case Report
Authors: Novizio Roberto , Corsello Andrea , Rizzo Gaetano Emanuele , Pontecorvi Alfredo , Locantore Pietro 
Published: February 2025

Background:
The primary presentation of SARS-CoV-2 infection is viral pneumonia,
which may be complicated by acute respiratory distress syndrome, although several other manifestations
can occur.. Endocrine implications have been described. Pheochromocytomas are rare tumors
mainly originating in the adrenal medulla. Symptoms are primarily due to catecholamine
overproduction and abrupt release. Catecholamine release is unregulated and could be continuous
or paroxysmal. Some conditions (i.e., stress, physical exercise, or specific foods) can trigger catecholamine
release. Sars-CoV-2 infections have not been previously described as precipitators of
adrenergic crises in pheochromocytoma patients. In this study, we report a case of adrenal crisis of
a patient affected by pheochromocytoma in the context of Sars-CoV-2 infection.

Case report:
A 63-year-old Caucasian male known for right adrenal pheochromocytoma waiting
for surgical removal was admitted to the Emergency Department (ED) in March 2021 for a fainting
episode and hypertensive crisis that he never experienced before.
The patient had a known medical history of type 2 mellitus diabetes and hypercholesterolemia
treated by slow-release metformin 500 mg/day and atorvastatin 40 mg/day and was not vaccinated
for Sars-CoV-2. Two months before, the patient was hospitalized in another hospital for myocardial
infarction with non-obstructive coronary arteries, and a chest-abdomen TC scan showed a
right adrenal lodge occupied by coarse formation. In the 24-h urine sample, metanephrines were
>5000 μg/24h and Normetanephrines >2500 μg/24h. Scintigraphy with 123I-Metaiodobenzylguanidine
(MIBG) showed accumulation in right adrenal gland formation, confirming the suspicion of
pheochromocytoma. No further areas of pathological uptake were present. Fort that, the patient
was started on alpha-blockers (doxazosin 2 mg twice/day). Two weeks later, the patient was also
prescribed metoprolol 50 mg twice/day.
When admitted to the Emergency Department (ED), Blood Pressure (BP) was 210/108 mmHg
with a heart rate of 105 bpm. A routine nasopharyngeal swab for Sars-CoV-2 was performed, resulting
positive. After an extra dosage of 2 mg of doxazosin and 20 mg of nifedipine, symptoms
addressed to catecholamine release disappeared. Being positive for Sars-CoV-19, the patient was
transferred to the infectious diseases department. High mean BP was demonstrated at the control
profile. Doxazosin was increased to 4 mg twice a day with a good effect on BP and tachycardia.
After 10 days, the SARS-CoV-2 swab result was negative, and the patient was discharged with
normal vital parameters and instructions to continue the increased dose of doxazosin. No other crisis
was reported until surgery, which was performed without any complications after 1 month.

Conclusion:
Since the adrenal crisis is a life-threatening condition, we suggest close BP monitoring
and therapeutic adherence in patients with pheochromocytoma waiting for surgery and living
in areas characterized by outbreaks of COVID-19 infection. Moreover, we suggest considering an
increase in alpha-blocker dosage to prevent the crisis.