Hypertensive crisis after endoscopic ultrasound-guided fine-needle aspiration of the right adrenal gland

A 51-year-old man was referred for endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) of a suspected adrenal metastasis of lung cancer. Computed tomography (CT) scans disclosed persistent pleural thickening of the right upper lobe after an episode of pneumonia, and an enlarged right adrenal gland ([Fig. 1]). At positron emission tomography CT (PET-CT) scan, both sites showed increased fluorodeoxyglucose (FDG) uptake. EUS with the patient under conscious sedation with midazolam and fentanyl demonstrated an enlarged, heterogeneous right adrenal gland of 50 mm diameter, with a hypoechogenic center ([Fig. 2]). Transduodenal FNA was performed twice with a 25-gauge needle (Echotip Ultra, Cook Endoscopy). During post-procedure monitoring for 2 h, only mild symptoms of nausea were observed and the patient was subsequently discharged.

Fig. 1 In a 51-year-old man with suspected adrenal metastasis of lung cancer, computed tomography (CT) scan showed an enlarged right adrenal gland with a heterogeneous appearance.

Fig. 2 Endoscopic ultrasound (EUS) of right adrenal gland. A heterogeneous mass of almost 5 cm with a hypoechogenic center was seen in the right adrenal gland.

However, 5 h after discharge, he was readmitted to the hospital with severe abdominal pain, vomiting, and shortness of breath. A tachypnoeic and somnolent man was seen, with marked peripheral vasoconstriction, and abdominal tenderness without guarding. Vital parameters showed blood pressure 155/100 mmHg, pulse rate 140 bpm, and oxygen saturation 73 %. Laboratory results showed a severe metabolic acidosis (pH 6.85; lactate 20 mmol/L), and hyperglycemia (glucose 37 mmol/L). Chest radiograph showed bilateral perihilar and interstitial edema. The patient was immediately admitted to the intensive care unit with a provisional diagnosis of hypertensive crisis and secondary acute decompensated heart failure, most likely due to puncture into a pheochromocytoma. Cytologic evaluation of the FNA specimen confirmed the diagnosis as it revealed irregularly arranged monomorphic cells with round nuclei, and positive staining for chromogranin ([Fig. 3 a, b]). After laparoscopic right-sided adrenalectomy for the pheochromocytoma, the patient slowly recovered, and was discharged home a few weeks later. Further pulmonological evaluation did not demonstrate lung cancer.

Fig. 3 Microscopy of cytology specimen: a hematoxylin and eosin (H&E) staining; b chromogranin staining.

Depending on its capacity to release catecholamines to the systemic circulation, pheochromocytoma may evoke mild or nonspecific signs and symptoms, and as a consequence, up to 15 % of tumors remain undiagnosed during life [1] [2]. EUS-guided FNA of adrenal pheochromocytomas without any complications has been described in small numbers in case series [3] [4] [5]. Accordingly, a recent American Society for Gastrointestinal Endoscopy guideline on adverse events associated with EUS-guided FNA does not describe the risk reported here [6]. Our case shows that EUS-guided puncture of pheochromocytoma may evoke an abrupt release of catecholamines, and subsequently, a life-threatening hypertensive crisis, similar to the well-known risk of percutaneous biopsy [2]. Based on this case, we advise exclusion of (subclinical) pheochromocytoma before all EUS-guided punctures of adrenal lesions, by 24-h urine collection for metanephrines and catecholamines [7].

Endoscopy_UCTN_Code_CPL_1AL_2AF

Competing interests: None

• References

• 1 Mannelli M, Lenders JW, Pacak K et al. Subclinical phaeochromocytoma. Best Pract Res Clin Endocrinol Metab 2012; 26: 507-515
• 2 Vanderveen KA, Thompson SM, Callstrom MR et al. Biopsy of pheochromocytomas and paragangliomas: potential for disaster. Surgery 2009; 146: 1158-1166
• 3 Akdamar MK, Eltoum I, Eloubeidi MA. Retroperitoneal paraganglioma: EUS appearance and risk associated with EUS-guided FNA. Gastrointest Endosc 2004; 60: 1018-1021
• 4 Eloubeidi MA, Eltoum I, Eloubeidi MA. A large single-center experience of EUS-guided FNA of the left and right adrenal glands: diagnostic utility and impact on patient management. Gastrointest Endosc 2010; 71: 745-753
• 5 DeWitt J, Alsatie M, LeBlanc J et al. Endoscopic ultrasound-guided fine-needle aspiration of left adrenal gland masses. Endoscopy 2007; 39: 65-71
• 6 Early DS, Acosta RD, Chandrasekhara V. ASGE Standards of Practice Committee et al. Adverse events associated with EUS and EUS with FNA. Gastrointest Endosc 2013; 77: 839-843
• 7 Sawka AM, Jaeschke R, Singh RJ et al. A comparison of biochemical tests for pheochromocytoma: measurement of fractionated plasma metanephrines compared with the combination of 24-hour urinary metanephrines and catecholamines. J Clin Endocrinol Metab 2003; 88: 553-558