Hypertension, sweating and palpitation in a psychotic patient – don’t miss the somatic cause

A 27-year-old man was admitted from prison because of acute psychosis. He was convinced of being part of a conspiracy system, he was not adequate in time and place, but there were no optical or auditory hallucinations. In his medical history there was a fracture of the right fourth finger, there was no positive family history for hypertension or cancer, he was not under any medical treatment, he was jobless and smoked a lot of cannabis. On admission the patient was hypertensive (164/ 95mmHg) and had a systolic murmur. Physical examination was otherwise unremarkable. Routine laboratory test was normal. Paliperidone treatment was successfully administered to treat psychosis. He complained about intermittent palpitations and increased sweating during the night. Because of the sinustachycardia and right-sided thoracic pain in combination with elevated d-dimers a pulmonary CT angiogram was performed. No pulmonary embolism was found but a truncated bilateral hypervascular lesion in both adrenal glands. MRI of adrenal glands showed a tumour measuring 3.4 3.7 cm on the right side and another one, measuring 1.1 1.3 cm on the left side (Figure 1). Further laboratory tests showed no hypercortisolism or hyperaldosteronism, but catecholamine and vanillin mandelic acid (VMA) levels in the 24-h urine sample (noradrenaline 1438 nmol/mmol Cr (reference <75), normetanephrine 3.48 nmol/mmol Cr (reference <0.18), VMA 17.9mmol/mmolCr (reference <3.0)) were elevated. Chromogranin A was considerably elevated (475 mg/l, reference 19–98 mg/l). Metaiodobenzylguanidine (MIBG) scintigraphy showed an intense tracer uptake in projection to both adrenal glands. No extraadrenal paragangliomas were detected. The genetic testing neither showed mutations in the SDHB or SDHD (succinate dehydrogenase B and D subunits) gene nor the typical mutations for MEN2 (multiple endocrine neoplasia) or von Hippel–Lindau syndrome (VHLS). After medical pretreatment with phenoxybenzamine the patient had total adrenalectomy on the right side and partial adrenalectomy on the left side without pre-, intraor postoperative hypertensive crisis. He required glucocorticoid substitution, initially administered IV, later on a maintenance dose of fludrocortisones 0.1mg/day. The diagnosis of a bilateral pheochromocytoma was histologically confirmed. The increased sweating and the palpitations disappeared after the surgery. The psychiatric treatment continued, the patient had regular sessions and continued the neuroleptic and antidepressant drug therapy as well. According to his psychiatrist, one and a half years later his condition is stable. He does not smoke cannabis and is starting a job. To keep his status he does not want to stop the medication at the moment.