A patient with intracardiac masses and an undiagnosed pheochromocytoma.

A 49-year-old man with a history of migraine headaches was referred to this institution with a diagnosis of pneumonia. He presented with fever, chills, diaphoresis, dehydration, a productive cough, and bilateral infiltrates on chest radiograph. Vital signs were as follows: temperature, 99.5°F; blood pressure, 195/114 mmHg; pulse rate, 122 beats/min; respiratory rate, 36 breaths/min; and oxygen saturation by pulse oximetry, 92% while receiving supplemental oxygen. The patient had an acutely ischemic right foot and complained of chest pain and right upper quadrant abdominal pain. An electrocardiogram showed diffuse T-wave changes. Laboratory analyses revealed normal serum electrolyte levels; normal coagulation studies; and elevations in serum glucose (979 mg/dL), fibrinogen (594 mg/dL), white blood cell count (21,000/mm3), hemoglobin (16.0 g/dlL), platelet count (482,000/mm3), and creatine phosphokinase (645 IU/L with a myocardial band fraction of 7 IU/L). Antibiotics were started for the presumed pneumonia. Intravenous heparin and nitroglycerin infusions were begun, and aspirin and metoprolol were given orally for suspected myocardial ischemia. A transthoracic echocardiogram showed mild concentric left ventricular hypertrophy; anterior, septal, and apical hypokinesis; a left ventricular ejection fraction of 40% to 50%; and 3 mobile pedunculated masses, each 0.5 to 1.0 cm in diameter, in the left ventricular apex (Fig 1). To evaluate the complaint of right upper quadrant pain, an abdominal ultrasound was obtained. Although no pathology was seen in the right upper quadrant, there was a question of a splenic infarction in the left upper quadrant. The patient developed new left facial weakness. His neurologic function deteriorated rapidly, and he became unresponsive except to deep pain. Magnetic resonance imaging (MRI) of the head revealed right cerebellar and cortical injuries. To maximize cerebral perfusion pressure, a neurology consultation recommended maintaining a systemic blood pressure of 170 to 200/85 to 100 mmHg using a phenylephrine infusion, as needed. A repeat transthoracic echocardiogram was unchanged except for the absence of 1 of the previously noted masses in the left ventricle. The patient’s neurologic examination was unchanged. Anticoagulation therapy was continued. In light of the electrocardiogram and echocardiogram, a cardiac catheterization was performed and revealed patent coronary arteries. During the procedure, the blood pressure increased from 160/80 mmHg to 210/110 mmHg after the administration of intravenous contrast material; this was treated with intravenous nitroglycerin. A lower extremity angiogram suggested extensive thrombus of the patient’s right femoral artery that was confirmed during subsequent exploration under monitored anesthesia care. Because of the patient’s multiple embolic events (cerebral, splenic, and lower extremity) and the documentation of left ventricular masses, a cardiac surgical consultation was requested to consider exploration and possible resection of the left ventricular masses. On hospital day 2, the patient was taken to the operating room for exploration of the left ventricular cavity using a transmitral approach. On arrival in the operating room, the patient’s arterial blood pressure and heart rate were 200/100 mmHg and 105 beats/min while receiving intravenous nitroglycerin. The neurologic examination had not changed. After placement of standard noninvasive monitors, intraarterial and pulmonary artery catheters were placed. The patient underwent a graded induction of anesthesia with 30 g/kg of fentanyl, 0.1 mg/kg of pancuronium, and 7 mg/kg of thiopental. In addition, 3% to 4% end-tidal isoflurane was given by mask ventilation. Before laryngoscopy, the blood pressure and heart rate decreased to 180/90 mmHg and 95 beats/min. Immediately after intubation, the patient’s arterial blood pressure and heart rate rose abruptly to 260/120 mmHg and 130 beats/min, followed by a rapid decline to 110/50 mmHg and 100 beats/min. Approximately 5 minutes later, during a period of no stimulation, the patient’s blood pressure increased dramatically again (Fig 2). Thiopental, 2 mg/kg, and labetalol, 5 mg, were given intravenously. Medication errors were ruled out, and the blood pressure measurement was confirmed by recalibrating the arterial pressure transducer and obtaining a noninvasive blood pressure. A presumptive diagnosis of pheochromocytoma was made. The patient received 45 mg of intravenous phentolamine in divided doses of 5 mg. An additional 14 g/kg of fentanyl and 13 mg of midazolam were given intravenously, and ventilation was maintained with 1.5% end-tidal isoflurane in oxygen. The patient also received 20 mg of phenoxybenzamine per orogastric tube. Hydration consisted of 3 L of lactated Ringer’s solution. Despite treatment, the arterial blood pressure continued its dramatic cyclical nature with peaks of 330 to 350/140 to 160 mmHg and nadirs of 80 to 90/40 to 50 mmHg (Fig 2). Given the working diagnosis of pheochromocytoma with poor hemodynamic control, the surgical case was postponed, and the patient was transferred to the intensive care unit. In the intensive care unit, aggressive therapy included sodium nitroprusside, esmolol, phenoxybenzamine, prazosin, diazoxide, labetalol, and volume administration. Repeat MRI of the head revealed a new frontal lobe infarct. Abdominal MRI disclosed a 10-cm left adrenal mass and no splenic infarction. Review of the patient’s preoperative abdominal ultrasound confirmed a left adrenal mass rather than a splenic infarction. Twenty-four-hour urine catecholamine levels were consistent with the diagnosis of pheochromocytoma (Table 1). From the Department of Anesthesia, Division of Cardiac Anesthesia, Beth Israel–Deaconess Medical Center, Harvard Medical School, Boston, MA. Address reprint requests to Stephanie W. Heindel, MD, Anesthesia Services of Eugene, P.C., 1200 Hilyard Street, Suite S-410, Eugene, OR 97401-8122. E-mail: stepheindel@yahoo.com Copyright 2002, Elsevier Science (USA). All rights reserved. 1053-0770/02/1603-0014$35.00/0 doi:10.1053/jcan.2002.124144