Pheochromocytoma: a devious opponent in a game of hide-and-seek.

M.G. is a 53-year-old woman with a history of episodic flushing, hypertension, and an incidentally discovered adrenal mass who presented with shortness of breath, weakness, and lightheadedness in the setting of hypertension to 300/200 mm Hg. Physical examination revealed an obese woman with a systolic ejection murmur and bibasilar crackles, but no neurological or ophthalmologic signs of hypertension. Plasma metanephrines were 0.50 nmol/L (normal: 0–0.49 nmol/L) and normetanephrines were 1.8 nmol/L (normal: 0–0.89 nmol/L); 24-hour urine epinephrine was 10 μg (normal: 0–20 μg) and norepinephrine was 119 μg (normal: 15–80 μg; Table). Autonomous hyperaldosteronism and hypercortisolism were excluded. Renal artery ultrasound was unremarkable; T2-weighted abdominal MRI revealed a 2.5 × 1.8 centimeter hypointense lesion in the right adrenal gland (Figure 1A). Presumed diagnosis was pheochro-mocytoma, for which appropriate pre-operative preparation and surgery, as described later, were conducted. Case 2 J.C. is a 30-year-old woman with a history of pregnancy-induced hypertension who presented with abdominal pain, vomiting, and bloody diarrhea. Physical examination was notable for normal vital signs and a mildly uncomfortable appearing woman with a systolic ejection murmur and diffusely tender abdomen. Plasma metanephrines were 0.31 nmol/L, and normetanephrines were 11.7 nmol/L; 24-hour urine epineph-rine was 18 μg, and norepinephrine was 804 μg (Table). T2-weighted abdominal MRI revealed a 36-mm heterogeneous left adrenal mass (Figure 1B). Presumed diagnosis was pheochromocytoma, for which appropriate preoperative preparation and surgery were conducted.