Sars-Cov-2 Infection as Catecholamin Crisis in Pheocreomocitoma: A Case Report

The primary presentation of SARS-CoV-2 infection is viral pneumonia, which may be complicated by acute respiratory distress syndrome, although several other manifestations can occur.. Endocrine implications have been described. Pheochromocytomas are rare tumors mainly originating in the adrenal medulla. Symptoms are primarily due to catecholamine overproduction and abrupt release. Catecholamine release is unregulated and could be continuous or paroxysmal. Some conditions (i.e., stress, physical exercise, or specific foods) can trigger catecholamine release. Sars-CoV-2 infections have not been previously described as precipitators of adrenergic crises in pheochromocytoma patients. In this study, we report a case of adrenal crisis of a patient affected by pheochromocytoma in the context of Sars-CoV-2 infection.

A 63-year-old Caucasian male known for right adrenal pheochromocytoma waiting for surgical removal was admitted to the Emergency Department (ED) in March 2021 for a fainting episode and hypertensive crisis that he never experienced before. The patient had a known medical history of type 2 mellitus diabetes and hypercholesterolemia treated by slow-release metformin 500 mg/day and atorvastatin 40 mg/day and was not vaccinated for Sars-CoV-2. Two months before, the patient was hospitalized in another hospital for myocardial infarction with non-obstructive coronary arteries, and a chest-abdomen TC scan showed a right adrenal lodge occupied by coarse formation. In the 24-h urine sample, metanephrines were >5000 μg/24h and Normetanephrines >2500 μg/24h. Scintigraphy with 123I-Metaiodobenzylguanidine (MIBG) showed accumulation in right adrenal gland formation, confirming the suspicion of pheochromocytoma. No further areas of pathological uptake were present. Fort that, the patient was started on alpha-blockers (doxazosin 2 mg twice/day). Two weeks later, the patient was also prescribed metoprolol 50 mg twice/day. When admitted to the Emergency Department (ED), Blood Pressure (BP) was 210/108 mmHg with a heart rate of 105 bpm. A routine nasopharyngeal swab for Sars-CoV-2 was performed, resulting positive. After an extra dosage of 2 mg of doxazosin and 20 mg of nifedipine, symptoms addressed to catecholamine release disappeared. Being positive for Sars-CoV-19, the patient was transferred to the infectious diseases department. High mean BP was demonstrated at the control profile. Doxazosin was increased to 4 mg twice a day with a good effect on BP and tachycardia. After 10 days, the SARS-CoV-2 swab result was negative, and the patient was discharged with normal vital parameters and instructions to continue the increased dose of doxazosin. No other crisis was reported until surgery, which was performed without any complications after 1 month.

Since the adrenal crisis is a life-threatening condition, we suggest close BP monitoring and therapeutic adherence in patients with pheochromocytoma waiting for surgery and living in areas characterized by outbreaks of COVID-19 infection. Moreover, we suggest considering an increase in alpha-blocker dosage to prevent the crisis.