Unexplained Symptomatic Paroxysmal Hypertension: a Diagnostic and Management Challenge
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Emory University School of Medicine, Atlanta, GA, USA; 2Division of General Medicine and Geriatrics, Department of Medicine, Emory University School of Medicine, Atlanta, USA.
J Gen Intern Med DOI: 10.1007/s11606-019-05503-8 © Society of General Internal Medicine 2019
INTRODUCTION
Symptomatic paroxysmal hypertension is considered the hallmark symptom of pheochromocytomas. Pheochromocytomas, however, are exceedingly rare and are diagnosed in 2% of patients with hypertensive paroxysms.1 As a result, clinicians and patients are often left frustrated and confused when a diagnostic evaluation of symptomatic paroxysmal hypertension is un-revealing for a pheochromocytoma. Frequently, these patients undergo multiple and often unnecessary testing, as was the case with our patient. The differential diagnosis is broader than most clinicians realize and includes conditions such as prescription and illicit drug use, obstructive sleep apnea, panic attacks, and pseudopheochromocytoma. Of these, pseudopheochromocytoma is perhaps the least understood and considered.
CASE
A 58-year-old woman with a past medical history of well controlled HIV and a diagnosis of seizure disorder presented with severe hypertension and headache. According to the patient’s husband, she was in her usual state of health until that morning when she developed abrupt onset of severe headache, nausea, palpitations, and anxiety. He reported that the patient had experienced previous similar episodes and had received care in multiple other hospitals. He also noted that the patient’s episodes were always preceded by an emotional stressor. On physical examination in the emergency department, the patient was noted to be drowsy. While alert and oriented with normal speech, she was reluctant to answer questions, stating that she was Btoo tired.^ Her blood pressure at presentation Prior presentations The manuscript was previously presented at the American College of Physicians Georgia Chapter Conference in Atlanta, in 2018. Received November 14, 2018 Revised May 31, 2019 Accepted October 10, 2019
was 260/120 mmHg with a heart rate of 130 beats per minute and normal respiratory rate and oxygen saturation. The patient’s blood pressure quickly dropped to 98/62 mmHg after receiving intravenous (IV) labetalol. Abdominal exam revealed generalized tenderness to palpation with mild voluntary guarding. The remainder of the physical examination was normal. Initial laboratory tests were revealing for an elevated white blood cell count of 18,000 cells per microliter but otherwise normal complete blood count, comprehensive metabolic profile, serum cardiac biomarkers, and urine drug screen. Magnetic resonance imaging/magnetic resonance angiogram of the brain (MRI/MRA) and 24-h electroencephalogram (EEG) were unremarkable. The patient was admitted to the hospital with a diagnosis of hypertensive urgency. She did not require any additional antihypertensive medications as she became hypotensive with the initial dose of labetalol and remained normotensive thereafter. An evaluation
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