A 39-year-old Thai female with poorly controlled hypertension presented with frequent sweating and palpitation. Urine metanephrine and normetanephrine were both high. Her computed tomography of abdomen images are shown above. 

1. Please describe the CT findings?

2. What is the most likely diagnosis? 

3. What is the treatment of choice?

โดย พญ.วิภาดา ส่งวัฒนา และ ร.อ.พัชรพันธ์ สุทธิวรรณ

ANSWERs

1. CT findings:  A large 13.7x8.6 cm heterogeneous well-defined, smooth margin mass, 34-HU unenhanced attenuation at Rt adrenal gland area with predominant hypodense area with some necrotic or cystic lesion and minimal calcification

  Differential diagnosis from imaging:  pheochromocytoma, adrenocortical carcinoma

2. Diagnosis (after laboratory investigations obtained):  Pheochromocytoma

3. Treatment:
- Rt adrenalectomy is the first choice of treatment if not contraindicated.
- Pre-operative BP control with alpha-blockers (e.g. doxazosin maximal dose of 32 mg/d), titrate to keep BP <130/80 mmHg, HR 60-70 bpm in sitting position and SBP >90 mmHg, HR 70-80 bpm in standing position
- A beta-blocker may be added after alpha-blocker admisnistration to control tachycardia.
- High sodium diet (>5g/d) and adequate fluid intake are suggested.

เรียบเรียงโดย นพ. สุวิชช์ บุญญาจรัสกุล และ พญ. ธนาภรณ์ โชติเอี่ยม แพทย์ประจำบ้านชั้นปีที่ 2 กองอายุรกรรม รพ.ภูมิพลอดุลยเดช พอ.