202: Pheochromocytoma Crisis After Intra-Articular Corticosteroid Injection

Introduction: Pheochromocytoma is a catecholamine-secreting tumor of chromaffin cells in the adrenal medulla, with an incidence of 0.6 per 100,000 person-years. In rare cases pheochromocytoma crisis (PC) occurs due to excessive catecholamine release, leading to life-threatening complications. PC may present with hypertension, hypotension, arrhythmias, hyperthermia, altered mentation, and organ dysfunction. PC is often triggered by surgery, trauma, or medications. Management is complex given unpredictable hemodynamics, avoidance of certain medications commonly used in critical care, and treatment with targeted pharmacologic therapy before surgical resection can safely be performed. Description: A 55-year-old man with hypertension and recent intra-articular glucocorticoid injection for knee pain presented with headache and vomiting. He developed labile blood pressures, fever to 102°F, and altered mental status requiring intubation. CT angiography revealed a 5.5 cm right adrenal mass with retroperitoneal hemorrhage. Plasma metanephrines were 20.8 nmol/L (ref 0–0.89) and normetanephrines 17.4 nmol/L (ref 0–0.49); 24-hour urine metanephrines were 26,223 µg/d (ref 55–320). He was diagnosed with ruptured pheochromocytoma and PC. After alpha-blockade and supportive care he stabilized and later underwent laparoscopic adrenalectomy following preoperative alpha and beta-blockade. Discussion: Steroid-induced PC is a known phenomenon, often associated with hemorrhagic tumor rupture. Glucocorticoid receptor up-regulation may enhance catecholamine synthesis and release in tumor cells. Most cases involve oral or IV steroids. This case is notable for onset after intra-articular injection. Along with glucocorticoids, other medications can precipitate or worsen PC. These include beta blockers without alpha blockers, vasopressors that stimulate adrenergic receptors, sedatives with sympathomimetic effects, opioids that induce histamine release, and antiemetics or antipsychotics with dopaminergic effects. In summary, PC should be suspected in undiagnosed patients with acute hemodynamic instability, severe hypertension, and recent steroid exposure. Clinicians should be cautious with pharmacologic choices in patients with pheochromocytoma.