Paroxysmal Hypertension in 29-Year-Old Male: Adrenal Mass Diagnosis

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📚 Internal Medicine Quiz

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📋 History

• 29-year-old male
• Paroxysmal hypertension
• On Amlodipine, Telmisartan, Indapamide
• No family history of hypertension

🩺 Examination

• Blood Pressure: 200/120 mmHg
• ECG: Sinus tachycardia
• Left ventricular hypertrophy (LVH)

🔬 Investigations

• Na: 134 mmol/L
• K: 3.5 mmol/L
• Creatinine: 1.1 mg/dL
• No proteinuria
• RBS: 5.9 mmol/L
• Lipid profile: Normal
• CT Abdomen: Rounded left adrenal mass

❓ MCQ Questions

Q1. Most likely diagnosis?

A. Renovascular Hypertension
B. Phaeochromocytoma
C. Primary Hyperaldosteronism
D. Cushing Syndrome

Q2. Most sensitive biochemical test?

A. 24-hour urinary VMA
B. Aldosterone/Renin ratio
C. Plasma Free Metanephrines
D. 24-hour urinary cortisol

Q3. Drug that must be started FIRST before surgery?

A. Propranolol
B. Phenoxybenzamine
C. Calcium Channel Blocker
D. ACE inhibitor

Q4. Definitive treatment?

A. Lifelong alpha-blocker
B. Radiofrequency ablation
C. Laparoscopic adrenalectomy
D. MIBG therapy

📝 Brief Case Summary

A young man presents with severe episodic hypertension despite triple-drug therapy. Examination reveals marked hypertension and sinus tachycardia. CT abdomen identifies a unilateral adrenal mass.

✅ Clickable Answer

Show Answers

Q1: B. Phaeochromocytoma

Q2: C. Plasma Free Metanephrines

Q3: B. Phenoxybenzamine

Q4: C. Laparoscopic Adrenalectomy

📖 Answer Explanation

Phaeochromocytoma is a catecholamine-secreting tumor arising from chromaffin cells of the adrenal medulla. Typical clues include paroxysmal hypertension, tachycardia, resistant hypertension, and an adrenal mass. Plasma free metanephrines are the most sensitive screening test. Alpha blockade must precede beta blockade to prevent unopposed alpha stimulation and hypertensive crisis. Surgical adrenalectomy is the definitive treatment.

❌ Why Not Others?

• Renovascular HTN: No renal bruit or kidney abnormalities.
• Primary Hyperaldosteronism: Potassium not significantly low.
• Cushing Syndrome: No cushingoid features.
• Urinary VMA: Less sensitive than plasma metanephrines.
• Propranolol first: Dangerous before alpha blockade.
• MIBG therapy: Reserved for metastatic/unresectable disease.

📚 Five Brief Case Scenarios

• Young patient with episodic headache, sweating, palpitations.
• Adrenal incidentaloma with resistant hypertension.
• MEN2 patient with severe hypertension.
• Hypertensive crisis during anesthesia induction.
• Pregnant woman with paroxysmal hypertension.

⚙️ Pathophysiology Simplified

Tumor cells produce excess catecholamines (epinephrine and norepinephrine). Sudden release causes vasoconstriction, tachycardia, sweating, headache, and severe episodic hypertension.

🩺 Physical Examination Pearls

• Marked hypertension
• Tachycardia
• Orthostatic hypotension after alpha blockade
• Signs of hypertensive heart disease
• Anxiety during attacks

🔎 Investigations – Choosing Wisely

• Plasma free metanephrines – best screening test
• 24-hour urinary fractionated metanephrines – confirmatory
• CT/MRI abdomen – localization
• MIBG scan – metastatic disease
• Genetic testing in young patients

💊 Management

• Alpha blockade (Phenoxybenzamine)
• High-salt diet and fluid loading
• Beta blocker only after alpha blockade
• Control hypertensive crises
• Laparoscopic adrenalectomy

📑 Differential Diagnosis

• Renovascular hypertension
• Primary hyperaldosteronism
• Cushing syndrome
• Hyperthyroidism
• Panic attacks
• Cocaine/amphetamine use

⚠️ Clinical Pitfalls

• Starting beta blocker before alpha blocker
• Ignoring adrenal incidentaloma
• Relying only on urinary VMA
• Missing hereditary syndromes
• Failure to optimize before surgery

💎 Clinical Pearls

• Think pheochromocytoma in resistant hypertension at a young age.
• Classic triad: headache, sweating, palpitations.
• Plasma metanephrines are highly sensitive.
• Alpha before beta blockade.
• Surgery is curative in most localized cases.

🔄 Monitoring & Follow-up

• Regular BP monitoring
• Postoperative plasma metanephrines
• Annual biochemical surveillance
• Screen for recurrence
• Genetic counseling when indicated

❔ FAQ

1. What is pheochromocytoma?
   A catecholamine-producing adrenal medullary tumor.
2. What is the classic triad?
   Headache, sweating, palpitations.
3. Why is hypertension episodic?
   Intermittent catecholamine release.
4. Best screening test?
   Plasma free metanephrines.
5. Best imaging modality?
   CT or MRI adrenal glands.
6. Why alpha blockade first?
   Prevents hypertensive crisis.
7. When add beta blocker?
   After adequate alpha blockade.
8. Definitive treatment?
   Surgical adrenalectomy.
9. What syndromes are associated?
   MEN2, VHL, NF1.
10. Role of MIBG scan?
    Localization of metastatic disease.
11. Can it be malignant?
    Yes.
12. Why genetic testing?
    Many cases are hereditary.
13. What ECG findings occur?
    Tachycardia and LVH.
14. Post-op monitoring?
    Metanephrine levels and BP.
15. Can recurrence occur?
    Yes, lifelong follow-up is advised.

📚 Key Guidelines & References

• Endocrine Society Clinical Practice Guideline on Pheochromocytoma & Paraganglioma
• European Society of Endocrinology Guidelines
• Harrison's Principles of Internal Medicine
• Oxford Handbook of Endocrinology
• UpToDate Review: Pheochromocytoma

🔍Keywords

Pheochromocytoma MCQ, Adrenal Tumor Quiz, Secondary Hypertension Case, Plasma Metanephrines, Phenoxybenzamine, Paroxysmal Hypertension, Resistant Hypertension MCQ, Adrenalectomy Quiz, Endocrinology MCQ, Internal Medicine Quiz

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