Hypertensive Urgency Secondary to a Malignant Pheochromocytoma and Its Complex Treatment Course: A Case Report

Pheochromocytoma originates from the chromaffin cells of the adrenal medulla. It produces an excess of catecholamines. It is essentially a benign tumour, and the malignant type represents a minority. The malignant behaviour can be unclear in the absence of metastases. Factors of poor prognosis in malignant pheochromocytoma include male sex, old age, large-sized tumours, the presence of metastases at the time of diagnosis and non-surgical treatment. The cornerstone treatment of pheochromocytoma is surgical excision. In the presence of metastases, chemotherapy can control the symptoms and prolong survival. Its reported side effects are usually few and mild. This report presents a rare case of malignant pheochromocytoma in a 26-year-old gentleman that first manifested as a hypertensive urgency. The patient had several recurrences and multiple metastases despite two surgical excisions. Such poor outcome could not be predicted initially by the known risk factors. A non-previously reported complication of treatment was acute lower limb ischaemia after the start of chemotherapy for the tumour, depriving the patient of completing the course. In conclusion, the presence of hypertension in young adults warrants the investigation for pheochromocytoma. Postoperative follow-up is mandatory to pick up early signs of malignancy and metastasis. Tumour breakdown by chemotherapy can cause various cardiovascular problems including acute limb ischaemia. The management can be quite challenging, therefore, a multidisciplinary team should look after the case. A palliative approach can be used in patients with severe symptoms and no chance of cure.