Graves’ disease allied with multiple pheochromocytoma
A female patient aged 22 years with no cardiovascular history was admitted to the hospital for ATH of 225/150 mmHg. The patient had suffered from intense headaches, palpitations, sweating, excessive nervousness, psychomotor agitation, and mood disturbances, as well as rapid weight loss 10 days before going to the hospital.\nEvaluation at admission showed a regular sinus tachycardia at 195 bpm demonstrated by electrocardiogram, a fever of 38.5°, exophthalmia, and a firm, homogeneous diffuse goiter with thrill. A whole-body CT scan showed five tissue and hypervascular masses of 26–30 mm in diameter, two bilateral adrenal, and three retropancreatic para-aortic masses [Figures and ]. Thyroid scintigraphy showed homogeneous increased uptake involving the whole thyroid gland. The highly probable diagnosis of pheochromocytoma was confirmed by the assay of urinary metabolites: normetanephrines = 112,126 nmol/24H (normal range: 300 to 2200), metanephrines = 1602 (normal range: 200 to 1500), and 3 orthomethyldopamine = 176,00 (normal range: 200 to 1400). Biological hyperthyroidism was evident with TSHus < 0.05 μUI/ml (normal range: 0.25 to 5), T3 = 24.37 pmol/l (normal range: 4 to 8.3), and T4 > 70 pmol/l (normal range: 9 to 20). Moreover, the biological workup showed glycemia at 6.60 μmol/l, urea at 7.83 μmol/l, serum creatinine at 74 μmol/l, and serum potassium at 3.8 mmol/l.\nTreatment in intensive care consisted of the simultaneous administration of nicardipine via electric pump syringe in decreasing doses of 4 mg/h, then 3, 2, and 1 mg/h of propranolol in intravenous bolus injections of 0.1 mg using an iterative technique, intravenous methylprednisolone dosed at 15 mg/kg and synthetic antithyroid drugs (carbimazole) at the dose of 60 mg/day, but no preoperative treatment preparation by (iodine) have been performed. Surgical excision of the tumors was done by laparotomy after 7 days and normalization of blood pressure and cardiac rate. It was conducted under general anesthesia using propofol, sufentanil, and cistracurium with invasive monitoring of arterial blood pressure and central venous pressure. The surgery was marked by several bouts of ATH and tachycardia, treated with a bolus of nicardipine and propranolol at 1 and 0.1 mg, respectively.\nThe surgical procedure consisted of the excision of five tumoral masses without adrenalectomy. The postoperative period was uncomplicated, allowing the discharge of the patient on the 5th postoperative day with no treatment beyond the synthetic antithyroid drug. The anatomic pathology examination confirmed the diagnosis of benign multiple pheochromocytoma.