24yo male with htn and HA

PATIENT: 24-year-old Caucasian  man, s' IO" (178 em),  I55lb (70·3 kg).

PRESENTATION: The  patient  presents  to your office with  primary  concerns  of high blood pressure and headaches. He has also been having episodes of feeling very anxious, with a nervous feeling that something bad is going to happen, even when  nothing is necessarily wrong.  He perspires  very easily and often, especially when he feels nervous. He measured his blood pressure several times over the past year when he happened to be at a pharmacy, and  noticed it has been high on multiple  occasions.  His  headaches

are intermittent and come at different times of day, lasting for about one hour  at a time,

with an aching sensation in his temples and forehead. He  has also noticed  that  he has lost about  I2  pounds over the past several months without changing his diet or lifest yle. He denies changes in urination or thirst.

ONSET: Onset was gradual over the past several years.

MEDICAL HISTORY: Unremarkable except for a fractured right  thumb from a snowboarding injury  5 years ago.

FAMILY HISTORY: His  mother  has bipolar  disorder  and is a recovering alcoholic. His father has hypertension.

PSYCHOSOCIAL: He works for a local book store as a clerk, and plays guitar in his free time. 

HEALTH HABITS: He  eats a vegan diet.  He smokes cigarettes socially, I-3 per week.

He doesn't  drink  alcohol.  He  doesn't  exercise regularly, but  he goes snowboarding in the winter  and  walks about  I mile to work.  He  finds that  exercising  makes him feel more  anxious.

ALLERGIES: NKDA. He  has a peanut  allergy. MEDICATIONS: None.

PHYSICAL EXAMINATION: The patient  is in no acute distress  but is perspiring on his forehead and underarms. Examination of extremities reveals cold perspiration of his hands  as well. Blood pressure  is I67/9o mmHg. Respiratory rate is 14/min. Heart rate is 88/min. Oral temperature is 98.6F  (37C). Head is atraumatic, normocephalic. PERRLA. Thyroid non-palpable. Lungs are clear to auscultation.' Heart rhythm is regular without murmurs. Abdominal exam reveals normal  bowel sounds, no palpable masses, bruits, or tenderness; the patient  reported experiencing an increased  heart  rate, perspiration, and  feeling of anxiety during the abdominal exam. Muscle strength and deep tendon reflexes are normal  in upper  and lower extremities.

PRELIMINARY LABS: None  at time of presentation.

IMAGING STUDIES: Axial T 2-weighted  MRI reveals a right suprarenal mass of high signal intensity measuring scm  in diameter.

1· Based on the patient's  symptoms and  MRI results,  the most likely diagnosis  is

- - - - -' but you must also consider        _

(a)      Pheochromocytoma; generalized anxiety disorder and essential hypertension

(b)       Cushing's disease; Fanconi's syndrome and panic disorder

(c)       Addison's disease; polycystic kidney disease and primary  hyperaldosteronism

(d)       Adrenal carcinoma; hypothyroidism and generalized anxiety disorder

2·  Which  laboratory testing would be most reliable to further confirm your diagnosis?

(a)      Urinary  morning cortisol

(b)       Salivary morning cortisol 

(c)        Plasma free metanephrines 

(d)         Urinary  n-telopeptide

3· This disease most often involves which portion of the affected gland:'

(a)     Posterior  pituitary 
(b)     Anterior  pituitary 
(c)     Adrenal cortex

(d)      Adrenal medulla

4.  You consider  prescribing  Rauvolfia serpentina liquid  extract  for this  patient's hypertension. What is the active constituent, medicinal part, and mechanism  of actic of this plant that would be indicated for high blood pressure:'

(a)      Ricinine; seed; anticholinergic

(b)      Reserpine; root; alpha antagonist

(c)      Limonene; leaf; alpha agonist

(d)      Salicin; bark; beta antagonist

5·  Which  of the following is most the appropriate initial conventional treatment for dm condition:'

(a)      Surgical  removal of the abdominal mass visualized on MRI, followed by beta blockers to control his blood pressure

(b)      Surgical removal of the abdominal mass, followed by referral for a psychiatric consult for evaluation

(c)       Alpha blocker followed by beta blocker for blood pressure control before surget"' 

(d)       Beta blocker followed by alpha blocker for blood pressure control  before surge

Answers

1· (a) A pheochromocytoma is a chromaffin  cell tumor  typically located  in the adrenal glands. It produces  catecholamines such as norepinephrine, causing anxie hypertension, and excessive perspiration. Hypertension can either  be persistent

or paroxysmal.  TI1is condition is actually a more common cause of hypertension than you might expect; approximately r/Iooo people with hypertension have a pheochromocytoma. Cushing disease can certainly  cause hypertension, but  this condition will typically cause weight gain as opposed  to weight loss, and the othe=­ options  in this answer do not match the symptom presentation of the case. Addi.sc-:: disease causes severe fatigue and low blood  pressure,  rather  than elevated blood pressure.  This could be a case of adrenal  carcinoma  or generalized  anxiety, but hypothyroidism is not consistent with these symptoms.

2. (c) Plasma  free metanephrines are ninety  percent  sensitive in the diagnosis  of pheochromocytoma. Urinary  free metanephrines are also very useful and diagnostic, with imaging studies  demonstrating a tumor.  Blood testing of metanephrines are superior to testing of catecholamines in urine or blood, because  metanephrines are consistently  elevated, and  norepinephrine and epinephrine vary throughout the

day. Urinary  catecholamine end products such as vanillylmandelic acid (VMA) and homovanillic acid (HVA) can be useful, but are actually much less specific than testing metanephrines. This is because VMA and HVA can be elevated from a neuroblastoma, sleep apnea, severe dehydration, extreme stress, several drugs, or large quantities of vanilla in food. N-telopeptide measures the degree of bone resorption in osteoporosis.

3.  (d) The  adrenal medulla  is affected in ninety  percent  of pheochromocytoma cases. Any part  of the  body that  originates from  neural  crest cells can develop a pheochromocytoma. Examples  include  the brain,  the carotid  body, sympathetic chain ganglia, the  retroperitoneal aspect of the aorta,  and  the aortic  bifurcation. Pheochromocytomas ate rarely malignant, but  if found  outside of the adrenal glands, the risk of malignancy rises to thirty  percent.

4.  (b) The  reserpine  alkaloids  from  the root of Rauvolfw serpentina  are very useful for the treatment of hypertension, anxiety, and have been used for schizophrenia. This plant can treat  schizophrenia because of its ability to inhibit  dopamine activity and thereby  reduce psychosis.  People with depression and low levels of dopamine may experience an aggravation  of depression symptoms with this herb (but  this is relatively rare).  Rauwolfia acts as an alpha blocker, leading to lower blood  pressure;  because

of this mechanism of action, it can have a side effect of nasal congestion  occasionally.

Ricinine is present  in the seed of Ricinus  communis  (castor). Limonene is one of the terpenoids present in the leaves of Rosmarinus  officina/is. Salicin is an anti-inflammatory constituent of Salix alba and S.nigra (white and black willow).

5. (c) In the conventional treatment of a pheochromocytoma, surgical removal of the tumor  is preferred. Medications to control  blood  pressure are used prior  to surgery. Alpha-blockers must  be used first, followed by beta-blockers to control  blood pressure, before surgery is performed.