A case of normotensive pheochromocytoma with management dilemma

We report an unusual case of normotensive pheochromocytoma detected incidentally, presenting a pre-operative management problem.

A 40-year-old lady with vague abdominal symptoms was initially discovered with a left adrenal incidentaloma by ultrasound abdomen, which was also revealed in computed tomography (CT). After exclusion of all the causes with possible necessary investigations, pheochromocytoma was confirmed with elevated 24 hour urinary metanephrine and normetanephrine. Her blood pressure was in low to normotensive range all throughout. She was attempted to be prepared with combined alpha and beta blockade but could not tolerate this regimen due to symptomatic hypotension. Subsequently, surgical preparation was planned cautiously with alpha-adenergic blockade only. With intensive monitoring, she underwent uneventful left adrenalectomy, and surgical pathology was consistent with pheochromocytoma.

This case illustrates an unusual presentation of normotensive pheochromocytoma as adrenal incidentaloma. Pre-operative preparation in these patients can be achieved with alpha-adrenergic blockade, adequate hydration, and liberal salt intake.