AUCTORES
Globalize your Research
Case Report | DOI: https://doi.org/10.31579/2690-4861/225
* Department of Pediatric Nephrology, Turkey
*Corresponding Author: Deniz Karakaya, Department of Pediatric Nephrology, Turkey
Citation: Deniz Karakaya*, Yazılıtaş F., Evrim K. Çakıcı , Güngör T., Çelikkaya E., Bülbül.M. (2022) A Case of Adrenal Pheochromocytoma Presenting with Anxiety. International Journal of Clinical Case Reports and Reviews. 11(4); DOI: 10.31579/2690-4861/225
Copyright: © 2022 Deniz Karakaya, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 30 May 2022 | Accepted: 06 June 2022 | Published: 18 June 2022
Keywords: adrenal pheochromocytoma; neuroendocrine tumor; adrenal medulla
Pheochromocytoma is a rare, neuroendocrine tumor secreting catecholamine, arising from chromaffin cells of the adrenal medulla. Also, very rare cause of secondary hypertension in pediatric age, and however, it is important to suspect. Presentation of this tumor is highly variable but the most common pediatric cases being persistent hypertension, tachycardia, sweating, and headache. In addition, anxiety, weight loss and recurrent hypertension may also appear among the clinical manifestations of the disease. The diagnosis requires measurement of plasma metanephrines, with imaging studies performed for localization and identification of metastatic lesions. The definitive management of hypertension is surgical. We present a case with pheochromocytoma that was previously diagnosed as anxiety due to tachycardia associated with hypertension.
Hypertension (HT) is a high prevalent disease worldwide. The prevalence of pediatric HT approximately 0.3% to 4.5% and 5–10% of cases have a secondary cause which may be potentially curable [1]. So, accurate diagnosis of secondary HT is extremely important. Secondary HT is more common in children than in adults. This possibility should be excluded in childhood hypertension who presents symptoms, signs and laboratorial findings suggestive or specific for a secondary cause [1].
Pheochromocytoma (PCC) is a rare neuroendocrine tumor, secreting catecholamine, arising from chromaffin cells, originating from the adrenal medulla. It is also rare among the pediatric population; with an annual incidence of 0.2–0.3 cases per million and representing 9.6–17.7% of all cases [2,3].
The clinical presentation of this tumor is highly variable, as a result of excessive secretion of catecholamines; includes HT, tachycardia, sweating and headache. Hypertension may be continuous or paroxysmal. Orthostatic hypotension (low plasma volume and adrenaline effect), blurred vision, papilla edema, weight loss, polyuria, polydipsia, hyperglycemia, leukocytosis, symptoms such as psychiatric disorders are less common [4,5]. Treatment is surgical and includes stabilization of the patient's clinic until the time of surgery. We reported a boy who presented previously misdiagnosed as a psychiatric anxiety disorder with weight loss and palpitation complaints and two years later admitted with permanent HT.
A 15-year-old boy was admitted to the outpatient clinic of Pediatric Nephrology at Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital for hypertension accompanied by headache, epigastric pain and weight gain.
Two years ago, his blood pressure was high when he was evaluated with similar complaints. He was diagnosed as anxiety disorder because of occasionally observed high blood pressure, tachycardia, headache and feeling nervous. He had received short-term anxiolytic treatment at that time. Then he discontinued his medication because his complaints sustained. Also, he was followed up in an eye center for macular edema for two years. The patient has not been taking any medications for the past year and there was no smoking use or alcohol consumption. He had no family history of any disease and HT.
On admission he had marked high blood pressure (170/110 mmHg) with 2/6 grade systolic murmur in mesocardiac area. Physical examination showed body mass index of 22.8 kg/m2, heart rate was 78 beats per minute-rhythmic and no fever, abdomen murmurs or palpable masses and edema. His neurological examination was normal. Funduscopic examination revealed swollen optic discs and macular star appearance. He had a normal complete blood count and normal renal function and hepatic enzymes. Serum cholesterol and triglyceride levels were normal. There was no proteinuria in urine analysis.
An aortic insufficiency and left ventricular hypertrophy was detected in echocardiography and ejection fraction (70%) was normal. Abdominal ultrasound (US) revealed a hypoechoic adrenal mass measuring 50 x 47 mm in size in the paravertebral area. Magnetic resonance imaging (MRI) showed a 65x45 mm hyper vascular lesion with a central necrotic region on the left adrenal gland, compatible with a PCC [Figure 1 and 2]. No extra-adrenal tumors were seen.
Thyroid and parathyroid ultrasound were normal. His other investigations were: blood renin 10.12 ng/ml/h (0.5-5 ng/ml/h), blood neuron-specific enolase 25.6 ng/mL (0-17 ng/mL), spot urine metanephrine 170.95 mcg/g creatinine (30-154 mcg/g), and urine metanephrine 254.59 µg/24h (52-341 µg/24h).
Alpha-adrenergic blocker, calcium channel blocker, angiotensin converting enzyme (ACE) inhibitor and beta blocker were given for blood pressure control. The patient's blood pressure was controlled during follow-up. Surgical intervention was recommended for further treatment and he was referred to an advanced center for surgical intervention. The patient had normal blood pressure control before and during the operation. There was no complication. Postoperatively, the patient was re-admitted to follow-up. His blood pressure was normal without anti-hypertensive medicine. The levels of 24-h urinary metanephrines and normetanephrines were normal. At the three-month follow-up, the patient's weight gain was approximately 10 kilograms.
In the present study, we reported a patient with pheochromocytoma, who was previously diagnosed as a psychiatric anxiety disorder due to presence of weight loss and tachycardia symptoms and HT.
Hypertension is an important health problem worldwide, is becoming widespread in childhood and may cause important complications. Various risk factors have been associated with pediatric HT. Secondary HT is more common in younger children resulting from reno-vascular or renal parenchymal disease (78–80% of causes), endocrine (11% of causes), cardiac (2% of causes), pulmonary and others [6,7,8]. Pheochromocytoma accounts for only 0.5-2% of secondary HT causes (6). Since Although PCC is the cause of very few secondary HT, it is a disease that must be kept in mind when evaluating a child with hypertension.
Pheochromocytoma, a rare chromaffin cell tumor, secretes catecholamine which is responsible for the symptoms such as weight loss, tachycardia, sweating, HT, headache and tachycardia. Also, orthostatic hypotension (low plasma volume and adrenaline effect), blurred vision, papilla edema, weight loss, polyuria, polydipsia, hyperglycemia, leukocytosis, symptoms such as psychiatric disorders are less common [4,5]. It is known that most of the pediatric patients have HT and most of them have continuous hypertension rather than paroxysmal HT as in our case. HT is associated with various complications. Retinopathy in the eye secondary to HT [9] and left ventricular hypertrophy [10] in the heart were observed in our patient. In our case; HT, weight loss and palpitations, which occurred two years ago, caused to be diagnosed with anxiety. Also, anxiety is one of the rare psychological findings of PCC [11]. Although not described as a typical symptom of PCC, anxiety is the fourth most common symptom reported by patients suffering of PCC (11).
Diagnosis is made by demonstrating increased urinary and plasma catecholamine and metabolites. Metanephrines increased in 95-97% of patients. Plasma metanephrine and normetanephrine levels are very high negative predictive values. Normal plasma concentrations eliminate the diagnosis of PCC [12]. In our patient, urinary methanephrine and blood neuron-specific enolase levels were found to be high consistent with and the diagnosis of PCC. After biochemical diagnosis of PCC, the next step is to detect the tumor, radiological imaging studies. Contrast enhanced computed tomography is recommended as the first-line imaging modality for evaluation with a reported sensitivity of 88–100%, while MRI has been recommended for detection of head and neck paragangliomas (PGL) [13], and positron emission tomography for metastatic disease [14,15]. It is necessary to have both anatomic and functional imaging when evaluating all pediatric patients who present with PCC/PGL. In our case, MRI was preferred in the second stage to evaluate the mass.
The definitive treatment of PCC is surgical removal of the tumor. The patient must be stabilized before the operation; blood pressure should be normal for at least 1-2 weeks and no arrhythmia. Medical treatment should be started when suspected about disease. The aim of treatment is to reduce symptoms, lower blood pressure, and prepare patients for surgery after localization of the tumor. The first choice in controlling blood pressure is phenoxybenzamine, a long-acting adrenergic blocking drug [16]. Alpha-blockade is the standard management preoperatively to prevent intraoperative hemodynamic instability during resection of a mass [16]. Pre-operative and postoperative well controlled blood pressure should be ensured because catecholamine can be discharged during operation. Recurrence or persistent hypertension may be seen in 25% of the cases [17]. It has not been detected in the follow-up of our case. Also urine or plasma catecholamines and their metabolites should be measured at two weeks postoperatively. The measurements are repeated every three months in the first year, and then are repeated every 6 or 12 months in follow-up [17]. Imaging should be performed after a few months in the postoperative period and then as often as required [17].
In conclusion, although catecholamine secreting tumors originating from chromaffin cells are rare, they should be considered in childhood that observed HT. Pheochromocytoma in children may present with different symptoms such as anxiety. Childhood HT should be investigated carefully before it is thought to be associated with psychological factors such as anxiety.
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
