Hypertensive Emergency Following Embolization of a Large Adrenal Myelolipoma–Adrenal Medullary Infarction, Pheochromocytoma, or Acute Sympathetic Discharge? A Case Report and Literature Review

ABSTRACT Objective: To describe a case of hypertensive emergency following embolization of a large myelolipoma. Methods: Using the case report format to present clinical, laboratory, imaging, and dynamic testing data supporting clinical decision making. This is accompanied by a literature review. Results: A 40-year-old male with a history of hypertension presented with acute right upper abdominal pain and shortness of breath. Imaging completed at the transferring facility revealed a large right adrenal mass encapsulating the inferior vena cava. The blood hemoglobin was 7.8 g/dL because of internal hemorrhage into the mass. He underwent embolization of arterial flow to the right adrenal mass. A hypertensive emergency developed, and endocrinology was consulted to evaluate for pheochromocytoma. The plasma and urine normetanephrine were elevated, but the corresponding metanephrines remained normal. Surgery was imminent, and a clonidine suppression test in the surgical intensive care unit resulted in 60% suppression of plasma norepinephrine concentrations. He was cleared for surgery. The pathologic findings confirmed giant myelolipoma with internal hemorrhage. Conclusion: A giant myelolipoma with compressive effects can mimic a pheochromocytoma. To support clinical decision making for short-notice surgical clearance, the clonidine suppression test proved to be a simple supplementary test to differentiate pheochromocytoma and hyperadrenergic state of critical illness. Abbreviations: BP blood pressure CT computed tomography HPLC high-performance liquid chromatography HU Hounsfield units IVC inferior vena cava