PHEOCHROMOCYTOMA AND HYPOGLYCEMIA

Lewis C. Weger, MPAS, PA-C Principles of Clinical Medicine

OBJECTIVES 

Define Pheochromocytoma Describe the Signs and Symptoms of Pheochromocytoma Discuss the Work-up and Treatment of Pheochromocytoma  

OBJECTIVES Define Hypoglycemia  Discuss the Clinical Signs and Symptoms of Hypoglycemia  Discuss the Work-up and Treatment of Hypoglycemia  Discuss Reactive (Post-prandial) Hypoglycemia  Compare true Hypoglycemia to Facticious Hypoglycemia  .

PHEOCHROMOCYTOMA ‡ Pheochromocytoma ‡ Paroxysmal Hypertension in the young to mid-adults predominantly ‡ Etiology ‡ Tumor of the adrenal medulla (90%) ± ± ± ± ± ~ 80% are unilateral and solitary excess epinephrine production excess Norepinephrine production ~ 10% of tumors are malignant part of the MEN ± II syndromes .

PHEOCHROMOCYTOMA ‡ Signs and Symptoms ‡ Paroxysmal ‡ Diagnostic Clues ± SIX ³H¶s´ ‡ Hypertension ‡ Headache ± throbbing (90%) ‡ Heart palpitations ± (73%) ‡ Hyperhidrosis ± (70%) ‡ Hypermetabolism ‡ Hyperglycemia .

Palpitations ‡ Associated Symptoms ± ± ± ± Anxiety and tremor Pallor and flushing (rare) Chest and epigastric pain Painless hematuria ‡ Timing of episodes ± One hour or less ± daily to months . Diaphoresis.PHEOCHROMOCYTOMA ‡ Classic Presentation ‡ Predominant Symptoms ± H/A.

80%) ± 24-hour urine Metanephrines ‡ S/S (76%. 94%) ± 24-hour Urine VMA ‡ S/S (63%. 89%) ± Plasma Catecholamines ‡ S/S (85%.PHEOCHROMOCYTOMA ‡ Diagnosis ‡ Stop all questionable medications ‡ Labs ± Plasma Free Metanephrines ‡ Sensitivity/Specificity (99%. 94%) .

PHEOCHROMOCYTOMA ‡ Diagnosis ‡ Radiology ± Adrenal CT scan ‡ S/S (93-100%. 70%) ± Adrenal MRI ‡ S/S (same as CT) ± MIBG scan ‡ Metaiodobenzyl-guanidine ‡ Good for looking for tumors in unusual places .

PHEOCHROMOCYTOMA ‡ Management ‡ Medical efforts before surgical ‡ Medical ± Alpha Adrenergic Receptor Antagonists ‡ Phenoxybenzamine ‡ Phentolamine ± Beta blocker AFTER Alpha! ‡ Propanolol ‡ Surgical .

HYPOGLYCEMIA ‡ Definition: A clinical syndrome of multiple etiologies that results in symptomatic or asymptomatic episodes of low blood glucose levels ‡ Terminology such as ³fasting´ or ³reactive´ (post-prandial) hypoglycemia is not really the best way to classify hypoglycemia .

‡ Factitious ± Malicious or intentional ingestion of oral hypoglycemics or injection of insulin to produce hypoglycemic condition . illness.HYPOGLYCEMIA ‡ Traditional Classifications: ‡ Reactive or Post-Prandial ± Symptoms follow several hours after eating ‡ Fasting ± Symptoms associated with lack of eating ‡ Secondary ± Symptoms caused by other reasons than those listed above ± meds. etc. insulin. disease.

HYPOGLYCEMIA ‡ New Thought Classifications: ‡ Healthy Patient Hypoglycemia ± consider all likely causes ± meds. ‡ Sick or ill Patient Hypoglycemia ± Consider all likely causes with emphasis on the illness-based causes . etc. medical conditions. insulinoma. drugs.

HYPOGLYCEMIA ‡ Diagnosis: ‡ Highly clinical in many instances ‡ Complete patient history ‡ Blood glucose level during symptomatic episode .

but they usually are consistent between episodes in any particular patient .HYPOGLYCEMIA ‡ Symptoms: A wide variety based upon two major categories ‡ Autonomic ‡ Neuroglycopenic ‡ Symptoms may vary between patients.

HYPOGLYCEMIA ‡ Autonomic ‡ Diaphoresis ‡ Tremors ‡ Flushing ‡ Anxiety ‡ Nausea .

HYPOGLYCEMIA ‡ Neuroglycopenic ‡ Dizziness ‡ Mental confusion ‡ Fatigue ‡ Dysarthria ‡ Headache ‡ Poor concentration or amnesia ‡ Seizures .

HYPOGLYCEMIA ‡ Mixed ± symptoms that have components of both autonomic and neuroglycopenic ‡ Hunger ‡ Blurred vision ‡ Drowsiness ‡ Weakness .

HYPOGLYCEMIA ‡ Physical Exam ‡ Usually normal by the time the patient is seen by the medical provider ‡ May present with minor abnormalities ‡ Signs are not specific for hypoglycemia in healthy patients ‡ Signs in ill patients will reflect those signs associated with that illness .

Quinine. ASA.HYPOGLYCEMIA ‡ Etiology ‡ Drugs ± ETOH. « ‡ Insulinomas ± hyperinsulinism ‡ Metabolic conditions like: ± ± ± ± ± ± Addison¶s Hypopituitarism Renal Failure Sepsis or shock Starvation ± anorexia nervosa Many others ± see table 339-1 & H/O .

HYPOGLYCEMIA ‡ Laboratory evaluation ‡ Serum Glucose ± most important ± normal result during symptomatic episode effectively rules out hypoglycemia-based condition ‡ 72-hour fast ± classic test for dx ± < 50mg/dL is termination point ‡ Beta cell polypeptides ± Insulin. Proinsulin ± value varies in relation to glucose . C-Peptide.

HYPOGLYCEMIA ‡ Laboratory evaluation ‡ Sulfonylureas & Meglitinides ± Beta cell polypeptide concentrations are identical to that noted with an insulinoma rules out factitious etiology if pts are using these meds ‡ Insulin antibodies ± High levels insulin autoimmune d/o ± Low level factitious hypoglycemia ‡ C-Peptide suppression test ± C-Peptide formed by conversion of proinsulin to insulin ± Low level exogenous source of insulin ± High level insulinoma likely .

MRI of the abdomen ± especially the pancreas ‡ Treatment: ± Surgery is the preferred method ± Medical treatment (Diazoxide) may be used for those patients who are not surgical candidates .HYPOGLYCEMIA ‡ Insulinoma ‡ Diagnosis by: ± patient history ± insulin levels ± US. Spiral CT.

HYPOGLYCEMIA ‡ Reactive Hypoglycemia ‡ Etiology: Prolongation of the effect of insulin as counter-regulatory mechanism is slow to shut off insulin ‡ Diagnosis by: ± patient history! ± insulin levels usually are normal ± glucose level during episode ± low ‡ Treatment: ± Multiple small meals versus large meals ± Mid morning and afternoon snack .

HYPOGLYCEMIA ‡ Factitious Hypoglycemia ‡ Etiology: Usually due to inappropriate administration of hypoglycemic meds or insulin ‡ Diagnosis by: ± ± ± ± ± patient history! insulin level during episode High C-Peptide level during episode Low glucose level during episode ± Low Sulfonylurea & Meglitinide level High. if present ‡ Treatment: ± STOP offending agent! ± Psych eval if deliberate covert use .

CONCLUSION  Defined Pheochromocytoma Described the Signs and Symptoms of Pheochromocytoma Discussed the Work-up and Treatment of Pheochromocytoma   .

CONCLUSION Defined Hypoglycemia  Discussed the Clinical Signs and Symptoms of Hypoglycemia  Discussed the Work-up and Treatment of Hypoglycemia  Discussed Reactive (Postprandial) Hypoglycemia  Compared true Hypoglycemia to Factitious Hypoglycemia  .