Letter to the Editor
Diffuse Alveolar Hemorrhage as First Manifestation of a Pheochromocytoma
Hemorragia alveolar difusa como primera manifestación clínica de un feocromocitoma
Roser Querol Ripoll, María Isabel del Olmo García
, Rosa Cámara Gómez, Juan Francisco Merino-Torres
Corresponding author
Departamento de Endocrinología y Nutrición, Hospital Universitario y Politécnico La Fe, Valencia, Spain
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(B) CT axial image with contrast medium showing heterogeneous left adrenal lesion, 46<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>40<span class="elsevierStyleHsp" style=""></span>mm.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Diffuse alveolar hemorrhage (DAH) is a clinical condition characterized by hemoptysis, anemia and dyspnea. The radiological pattern of this disease is defined by ground-glass consolidations and interlobular septal thickening (crazy-paving pattern). Causes are multiple and include malignancy, infections, autoimmune diseases, coagulopathies and pulmonary hypertension. Pheochromocytoma is a tumor derived from chromaffin cells that typically presents as arterial hypertension (HT) associated with diaphoresis, tachycardia and headache. We describe below the case of a patient whose initial clinical manifestation of pheochromocytoma was massive hemoptysis and acute coronary syndrome. This case demonstrates the importance of considering pheochromocytoma as a possible diagnosis in cases of DAH with no apparent cause.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 68-year-old male was seen in the emergency room after an episode of frank hemoptysis associated with oppressive chest pain, nausea, sweating and pallor. Dyspnea, cold sweats and pallor were confirmed on physical examination. BP>180/100<span class="elsevierStyleHsp" style=""></span>mmHg, HR 120<span class="elsevierStyleHsp" style=""></span>bpm. There were no significant changes on ECG and bilateral diffuse alveolar pattern was observed on chest X-ray. Laboratory test parameters of note included blood glucose 257<span class="elsevierStyleHsp" style=""></span>mg/dl, leukocytosis with neutrophilia, hemoglobin 14<span class="elsevierStyleHsp" style=""></span>g/dl (MCV normal), creatinine 1.19<span class="elsevierStyleHsp" style=""></span>mg/dl, urea 62<span class="elsevierStyleHsp" style=""></span>mg/dl, troponin T 596.6<span class="elsevierStyleHsp" style=""></span>ng/l and CK 186<span class="elsevierStyleHsp" style=""></span>U/l. Arterial blood gases were compatible with hypoxemic respiratory failure (PaO<span class="elsevierStyleInf">2</span> 51.4<span class="elsevierStyleHsp" style=""></span>mmHg). Non-ST segment elevation acute coronary syndrome with hemoptysis was suspected, so the patient was admitted to the ICU where double antiplatelet therapy was initiated but not anticoagulation, due to hemoptysis. The patient had another episode of frank hemoptysis associated with a hypertensive crisis requiring oxygen therapy and intravenous bolus administration of methylprednisolone. The clinical picture improved within hours with normalization of renal function and anemia (Hb 10.9<span class="elsevierStyleHsp" style=""></span>g/dl). When the patient was interviewed again, he reported episodes of headache, sweating and palpitations on performing Valsalva manoeuvers. CT showed a crazy-paving lung pattern, ground-glass consolidations and interlobular septal thickening, compatible with alveolar hemorrhage (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A) and heterogeneous left adrenal lesion 46<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>40<span class="elsevierStyleHsp" style=""></span>mm (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). Raised catecholamine and metanephrine levels in urine (noradrenaline 1208.4<span class="elsevierStyleHsp" style=""></span>μg/24<span class="elsevierStyleHsp" style=""></span>h, adrenaline 532<span class="elsevierStyleHsp" style=""></span>μg/24<span class="elsevierStyleHsp" style=""></span>h, normetanephrine 5748.6<span class="elsevierStyleHsp" style=""></span>μg/24<span class="elsevierStyleHsp" style=""></span>h, metanephrine 12,281.6<span class="elsevierStyleHsp" style=""></span>μg/24<span class="elsevierStyleHsp" style=""></span>h) confirmed the diagnosis of pheochromocytoma. The patient was treated with alpha blockers (phenoxybenzamine 10<span class="elsevierStyleHsp" style=""></span>mg/8<span class="elsevierStyleHsp" style=""></span>h), later combined with a beta blocker (propranolol 10<span class="elsevierStyleHsp" style=""></span>mg/8<span class="elsevierStyleHsp" style=""></span>h). After 7 days of progressive improvement, fiberoptic laryngoscopy revealed pharynx and larynx free of bleeding and bronchoscopy was normal. Bronchoalveolar lavage contained no malignant cells and abundant hemosiderophages (>20%). Anti-DNA, c-ANCA, anti-MPO and anti-GBM antibodies and cultures were negative. After the patient stabilized, left adrenalectomy was performed by laparoscopy; the pathology examination revealed pheochromocytoma with malignant histological features. During follow-up the patient remained asymptomatic and all tests requested were normal (2 months after the episode, the patient had a PaO<span class="elsevierStyleInf">2</span> of 85<span class="elsevierStyleHsp" style=""></span>mmHg).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">On rare occasions pheochromocytoma can present with atypical manifestations such as hemoptysis, acute coronary syndrome with normal coronary catheterization or dilated cardiomyopathy.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Pathophysiological mechanisms most often involved in hemoptysis are lung metastases and coagulation disorders.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> When all of these have been ruled out, hemoptysis may be related to the hypertensive crisis triggered by cromaffin tumor secretion.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> In these cases, the paroxystic HT crises will produce pulmonary vein hypertension causing capillary rupture and the passage of erythrocytes to the alveolar space, resulting in hemoptysis. The interest in this case is that the presence of pheochromocytoma should be considered in the differential diagnosis of DAH of unknown origin, and that failure to diagnose may be potentially fatal.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Querol Ripoll R, del Olmo García MI, Cámara Gómez R, Merino-Torres JF. Hemorragia alveolar difusa como primera manifestación clínica de un feocromocitoma. Arch Bronconeumol. 2014;50:412–413.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1555 "Ancho" => 1000 "Tamanyo" => 238012 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) CT axial image showing crazy-paving lung pattern: ground-glass consolidations and interlobular septal thickening. (B) CT axial image with contrast medium showing heterogeneous left adrenal lesion, 46<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>40<span class="elsevierStyleHsp" style=""></span>mm.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cardiovascular manifestations of pheochromocytoma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "W.B. Liao" 1 => "C.F. Liu" 2 => "C.W. Chiang" 3 => "C.T. Kung" 4 => "C.W. 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Blair" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Clin Hypertens" "fecha" => "1986" "volumen" => "1" "paginaInicial" => "65" "paginaFinal" => "67" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Intraalveolar hemorrhage revealing pheochromocytoma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "N. Boarvis" 1 => "M. Fartoukh" 2 => "S. Christin-Maitre" 3 => "T. Francois" 4 => "A. Parrot" 5 => "C. Mayand" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Rev Pneumol Clin" "fecha" => "2006" "volumen" => "62" "paginaInicial" => "43" "paginaFinal" => "48" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16604041" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15792129/0000005000000009/v1_201408240420/S157921291400202X/v1_201408240420/en/main.assets" "Apartado" => array:4 [ "identificador" => "14576" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Letters to the editor" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/15792129/0000005000000009/v1_201408240420/S157921291400202X/v1_201408240420/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S157921291400202X?idApp=UINPBA00003Z" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 1 | 1 | 2 |
| 2024 October | 55 | 22 | 77 |
| 2024 September | 50 | 13 | 63 |
| 2024 August | 96 | 47 | 143 |
| 2024 July | 58 | 23 | 81 |
| 2024 June | 88 | 20 | 108 |
| 2024 May | 95 | 35 | 130 |
| 2024 April | 57 | 27 | 84 |
| 2024 March | 53 | 23 | 76 |
| 2024 February | 51 | 22 | 73 |
| 2023 March | 9 | 3 | 12 |
| 2023 February | 68 | 27 | 95 |
| 2023 January | 77 | 33 | 110 |
| 2022 December | 60 | 30 | 90 |
| 2022 November | 62 | 27 | 89 |
| 2022 October | 83 | 27 | 110 |
| 2022 September | 60 | 27 | 87 |
| 2022 August | 68 | 44 | 112 |
| 2022 July | 74 | 46 | 120 |
| 2022 June | 73 | 41 | 114 |
| 2022 May | 96 | 46 | 142 |
| 2022 April | 112 | 30 | 142 |
| 2022 March | 106 | 39 | 145 |
| 2022 February | 112 | 29 | 141 |
| 2022 January | 138 | 28 | 166 |
| 2021 December | 92 | 44 | 136 |
| 2021 November | 93 | 46 | 139 |
| 2021 October | 90 | 47 | 137 |
| 2021 September | 85 | 53 | 138 |
| 2021 August | 75 | 47 | 122 |
| 2021 July | 66 | 28 | 94 |
| 2021 June | 116 | 42 | 158 |
| 2021 May | 120 | 35 | 155 |
| 2021 April | 193 | 73 | 266 |
| 2021 March | 125 | 26 | 151 |
| 2021 February | 64 | 24 | 88 |
| 2021 January | 60 | 19 | 79 |
| 2020 December | 139 | 28 | 167 |
| 2020 November | 65 | 19 | 84 |
| 2020 October | 47 | 16 | 63 |
| 2020 September | 58 | 13 | 71 |
| 2020 August | 68 | 25 | 93 |
| 2020 July | 65 | 31 | 96 |
| 2020 June | 61 | 15 | 76 |
| 2020 May | 59 | 12 | 71 |
| 2020 April | 55 | 27 | 82 |
| 2020 March | 49 | 18 | 67 |
| 2020 February | 54 | 22 | 76 |
| 2020 January | 68 | 23 | 91 |
| 2019 December | 61 | 23 | 84 |
| 2019 November | 143 | 27 | 170 |
| 2019 October | 189 | 19 | 208 |
| 2019 September | 184 | 12 | 196 |
| 2019 August | 94 | 14 | 108 |
| 2019 July | 54 | 27 | 81 |
| 2019 June | 96 | 21 | 117 |
| 2019 May | 70 | 23 | 93 |
| 2019 April | 88 | 29 | 117 |
| 2019 March | 98 | 36 | 134 |
| 2019 February | 55 | 24 | 79 |
| 2019 January | 81 | 11 | 92 |
| 2018 December | 64 | 20 | 84 |
| 2018 November | 87 | 28 | 115 |
| 2018 October | 90 | 18 | 108 |
| 2018 September | 39 | 14 | 53 |
| 2018 May | 25 | 0 | 25 |
| 2018 April | 67 | 7 | 74 |
| 2018 March | 57 | 6 | 63 |
| 2018 February | 50 | 7 | 57 |
| 2018 January | 49 | 3 | 52 |
| 2017 December | 60 | 5 | 65 |
| 2017 November | 65 | 4 | 69 |
| 2017 October | 79 | 13 | 92 |
| 2017 September | 45 | 7 | 52 |
| 2017 August | 80 | 10 | 90 |
| 2017 July | 75 | 6 | 81 |
| 2017 June | 96 | 10 | 106 |
| 2017 May | 89 | 5 | 94 |
| 2017 April | 90 | 8 | 98 |
| 2017 March | 62 | 48 | 110 |
| 2017 February | 45 | 4 | 49 |
| 2017 January | 39 | 4 | 43 |
| 2016 December | 60 | 5 | 65 |
| 2016 November | 67 | 6 | 73 |
| 2016 October | 71 | 8 | 79 |
| 2016 September | 72 | 9 | 81 |
| 2016 August | 72 | 6 | 78 |
| 2016 July | 46 | 12 | 58 |
| 2016 March | 1 | 0 | 1 |
| 2016 February | 2 | 0 | 2 |
| 2015 December | 3 | 0 | 3 |
| 2015 October | 66 | 1 | 67 |
| 2015 September | 102 | 11 | 113 |
| 2015 August | 46 | 11 | 57 |
| 2015 July | 39 | 9 | 48 |
| 2015 June | 48 | 5 | 53 |
| 2015 May | 35 | 8 | 43 |
| 2015 April | 35 | 10 | 45 |
| 2015 March | 39 | 6 | 45 |
| 2015 February | 42 | 8 | 50 |
| 2015 January | 32 | 8 | 40 |
| 2014 December | 23 | 14 | 37 |
| 2014 October | 0 | 1 | 1 |
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