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Special Feature |

Image of the Month—Quiz Case FREE

Lawrence Huan, BS; Bernard M. Jaffe, MD; Emad Kandil, MD
[+] Author Affiliations

Author Affiliations: Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana.


SECTION EDITOR: CARL E. BREDENBERG, MD


Arch Surg. 2011;146(8):985. doi:10.1001/archsurg.2011.189-a.
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Published online

A 21-year-old man had a 2-year history of persistent hypertension, poorly controlled with doxazosin mesylate and nicardipine hydrochloride. He reported episodic diaphoresis and headaches at rest on a daily basis. The patient was otherwise healthy with no neurological symptoms, palpitations, constipation, abdominal pain, or other gastrointestinal complaints. He also denied fever, weight loss, cough, hemoptysis, bone pain, or other symptoms suggestive of metastatic disease. His physical examination was normal and he had no palpable neck masses. His plasma electrolyte levels and urinalysis results were normal during routine visits to his primary care physician. He had a normal electrocardiograph and no apparent cardiac anomalies.

The patient's laboratory workup included normal plasma aldosterone (5.9 ng/dL; normal, <21 ng/dL) and renin (2.0 ng/mL; normal, 1.9-3.7 ng/mL) levels. His free plasma metanephrine level was shown to be elevated (2.92 nmol/L; normal, <0.89 nmol/L). His 24-hour urine catecholamine excretion rate revealed elevated norepinephrine (501 μg/24 h; normal, 15-80 μg/24 h) but normal dopamine (327 μg/24 h; normal, 65-400 μg/24 h) and epinephrine (12 μg; normal, <20.0 μg) levels. His plasma catecholamine level showed normal dopamine (37 pg/mL [to convert to picomoles per liter, multiply by 6.528]; normal, <142 pg/mL) and epinephrine (43 pg/mL [to convert to picomoles per liter, multiply by 5.459]; normal, <99 pg/mL) levels with an elevated level of norepinephrine (2560 pg/mL [to convert to picomoles per liter, multiply by 5.911]; normal, <142 pg/mL). Iodine 123–labeled metaiodobenzylguanidine scintigraphy (Figure 1) and computed tomographic scan of the abdomen and pelvis (Figure 2) were performed.

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Graphic Jump Location

Figure 1. Metaiodobenzylguanidine scintigraphy showing increased uptake in the region of the aortic bifurcation.

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Graphic Jump Location

Figure 2. Computed tomographic scan cut of the abdomen with a 2.5-cm mass adjacent to the aorta, immediately inferior to the origin of the inferior mesenteric artery (IMA).

WHAT IS THE DIAGNOSIS?

A.  Metastatic adrenal pheochromocytoma

B.  Paraganglioma

C.  Ganglioneuroma

D.  Glomus tumor

Figures

Place holder to copy figure label and caption
Graphic Jump Location

Figure 1. Metaiodobenzylguanidine scintigraphy showing increased uptake in the region of the aortic bifurcation.

Place holder to copy figure label and caption
Graphic Jump Location

Figure 2. Computed tomographic scan cut of the abdomen with a 2.5-cm mass adjacent to the aorta, immediately inferior to the origin of the inferior mesenteric artery (IMA).

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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