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A symptomatic de novo pheochromocytoma 23 years after liver transplantation: a case report and review of the literature.

Montenovo MI, Jalikis FG, Hoch B, Bakthavatsalam R - Case Rep Transplant (2014)

Bottom Line: We report a case of subacute onset of headaches and tremors with a newly discovered adrenal pheochromocytoma 23 years after an orthotopic liver transplantation and provide a review of the scarce literature regarding endocrine malignancies in liver transplant recipients.We describe the clinical presentation, diagnostic work-up, and management.A broad differential diagnosis should always be included in the study of any abnormalities in this patient population.

View Article: PubMed Central - PubMed

Affiliation: Division of Transplantation, Department of Surgery, University of Washington, Seattle, WA, USA.

ABSTRACT
We report a case of subacute onset of headaches and tremors with a newly discovered adrenal pheochromocytoma 23 years after an orthotopic liver transplantation and provide a review of the scarce literature regarding endocrine malignancies in liver transplant recipients. We describe the clinical presentation, diagnostic work-up, and management. This is the second case report in the literature of a de novo pheochromocytoma after solid organ transplantation. It shows that new-onset common symptoms in transplant recipients are always challenging and deserve a very thorough work-up until the cause of the symptoms is elucidated. A broad differential diagnosis should always be included in the study of any abnormalities in this patient population.

No MeSH data available.


Related in: MedlinePlus

Gross appearance of the pheochromocytoma specimen.
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fig2: Gross appearance of the pheochromocytoma specimen.

Mentions: A 61-year-old lady with a history of end-stage liver disease secondary to autoimmune hepatitis after orthotopic liver transplantation in 1990 presented at her annual check-up clinic with new-onset episodic tremors and debilitating migraines. She had a previous history of tremors immediately after the transplant which disappeared after several months. Over the last year she has developed recurrent episodic tremors which have significantly progressed in the last few months. She also developed a new onset of episodic severe headaches without aura for which she was started on sumatriptan with only partial relief. She denied any shortness of breath, palpitations, or hypertension. There was no other significant medical history. She denies any family history concerning pheochromocytoma or multiple endocrine neoplasia syndrome. For immunosuppression, she was on cyclosporine 100 mg QD, azathioprine 50 mg QD, and prednisone 1 mg QD. Her routine annual abdominal ultrasound protocol showed a new incidental heterogeneous mass measuring 3.1 cm × 2.2 cm × 2.6 cm in the right adrenal gland. A computed tomography with intravenous contrast demonstrated a 2.9 cm × 2.8 cm indeterminate nodule in the right adrenal mass of intermediate density (42 HU). A 24-hour urine collection demonstrated total urine metanephrines of 2,973 mcg/24 hr (reference <616 mcg/24 hr) and urine normetanephrine of 2,304 mcg/24 hr (reference <521 mcg/24 hr). An MIBG (iodine-123-meta-iodobenzylguanidine) scan showed avid uptake of radiotracer in the right adrenal gland with otherwise normal physiological distribution (Figure 1). The patient was started on phenoxybenzamine 10 mg BID ten days before the operation and titrated to orthostatic symptoms. She was admitted the day before the operation for appropriate hydration and underwent an uneventful open right adrenalectomy. She was discharged home on postoperative day 5, free of tremors and headaches. The final pathology report showed a pheochromocytoma (Figures 2 and 3).


A symptomatic de novo pheochromocytoma 23 years after liver transplantation: a case report and review of the literature.

Montenovo MI, Jalikis FG, Hoch B, Bakthavatsalam R - Case Rep Transplant (2014)

Gross appearance of the pheochromocytoma specimen.
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4279711&req=5

fig2: Gross appearance of the pheochromocytoma specimen.
Mentions: A 61-year-old lady with a history of end-stage liver disease secondary to autoimmune hepatitis after orthotopic liver transplantation in 1990 presented at her annual check-up clinic with new-onset episodic tremors and debilitating migraines. She had a previous history of tremors immediately after the transplant which disappeared after several months. Over the last year she has developed recurrent episodic tremors which have significantly progressed in the last few months. She also developed a new onset of episodic severe headaches without aura for which she was started on sumatriptan with only partial relief. She denied any shortness of breath, palpitations, or hypertension. There was no other significant medical history. She denies any family history concerning pheochromocytoma or multiple endocrine neoplasia syndrome. For immunosuppression, she was on cyclosporine 100 mg QD, azathioprine 50 mg QD, and prednisone 1 mg QD. Her routine annual abdominal ultrasound protocol showed a new incidental heterogeneous mass measuring 3.1 cm × 2.2 cm × 2.6 cm in the right adrenal gland. A computed tomography with intravenous contrast demonstrated a 2.9 cm × 2.8 cm indeterminate nodule in the right adrenal mass of intermediate density (42 HU). A 24-hour urine collection demonstrated total urine metanephrines of 2,973 mcg/24 hr (reference <616 mcg/24 hr) and urine normetanephrine of 2,304 mcg/24 hr (reference <521 mcg/24 hr). An MIBG (iodine-123-meta-iodobenzylguanidine) scan showed avid uptake of radiotracer in the right adrenal gland with otherwise normal physiological distribution (Figure 1). The patient was started on phenoxybenzamine 10 mg BID ten days before the operation and titrated to orthostatic symptoms. She was admitted the day before the operation for appropriate hydration and underwent an uneventful open right adrenalectomy. She was discharged home on postoperative day 5, free of tremors and headaches. The final pathology report showed a pheochromocytoma (Figures 2 and 3).

Bottom Line: We report a case of subacute onset of headaches and tremors with a newly discovered adrenal pheochromocytoma 23 years after an orthotopic liver transplantation and provide a review of the scarce literature regarding endocrine malignancies in liver transplant recipients.We describe the clinical presentation, diagnostic work-up, and management.A broad differential diagnosis should always be included in the study of any abnormalities in this patient population.

View Article: PubMed Central - PubMed

Affiliation: Division of Transplantation, Department of Surgery, University of Washington, Seattle, WA, USA.

ABSTRACT
We report a case of subacute onset of headaches and tremors with a newly discovered adrenal pheochromocytoma 23 years after an orthotopic liver transplantation and provide a review of the scarce literature regarding endocrine malignancies in liver transplant recipients. We describe the clinical presentation, diagnostic work-up, and management. This is the second case report in the literature of a de novo pheochromocytoma after solid organ transplantation. It shows that new-onset common symptoms in transplant recipients are always challenging and deserve a very thorough work-up until the cause of the symptoms is elucidated. A broad differential diagnosis should always be included in the study of any abnormalities in this patient population.

No MeSH data available.


Related in: MedlinePlus