A 44-year-old woman comes to the office due to worsening anxiety. Prior to starting her new job 3 months ago, the patient had not suffered from anxiety or any other psychiatric condition. She experiences the demands of her new job as overwhelming and disproportionate to the support and resources she has available at work. Around the same time that she started her new job, the patient began to suffer sudden episodes of palpitations, sweating, pounding headache, and panicky feelings that have recurred every few days for no apparent reason. The patient was also recently diagnosed with hypertension that has only slightly improved with antihypertensive medication. Temperature is 37.2 C (99 F), blood pressure is 184/86 mm Hg, pulse is 91/min, and respirations are 14/min. BMI is 23 kg/m². The patient appears anxious, mildly tremulous, and diaphoretic on examination. Laboratory results are as follows: Which of the following is the most likely explanation for this patient's symptoms?

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11ec25c8_d77b_945b_bc81_bf1325f3465e_MD0003_00 This patient's episodic headache, diaphoresis, tachycardia/palpitations, and anxiety symptoms in the setting of new-onset, drug-resistant hypertension and hyperglycemia with normal BMI are consistent with a diagnosis of pheochromocytoma. Signs and symptoms of pheochromocytoma are caused by catecholamine excess. However, only 50% of patients with pheochromocytoma are symptomatic, and even in symptomatic individuals, the diagnosis is frequently missed due to the intermittent nature of symptoms. Pheochromocytoma is most commonly diagnosed at age 30-50 and is associated with the autosomal dominant disorders of von Hippel-Lindau syndrome, multiple endocrine neoplasia type 2, and neurofibromatosis type 1. Measurements of urinary and/or plasma fractionated metanephrines and catecholamines are used to make the diagnosis. Physicians must have a high index of suspicion for pheochromocytoma as it may be misdiagnosed as a psychiatric disorder in otherwise asymptomatic patients. (Choice A) Acute intermittent porphyria is an autosomal dominant disorder of heme synthesis that presents with episodic abdominal pain, tachycardia, and peripheral neuropathy. (Choice B) Carcinoid syndrome is most commonly associated with intestinal neuroendocrine tumors and presents with intermittent diarrhea and skin flushing; it is sometimes associated with pulmonary and/or tricuspid valvular disease. (Choices C and F) Patients with generalized anxiety disorder and panic disorder may have similar psychiatric and sympathetically driven somatic symptoms (eg, palpitations, diaphoresis) as those found in pheochromocytoma; however, severe, drug-resistant hypertension, hyperglycemia, and episodic pounding headache are not associated with either condition. (Choice D) Although hyperthyroidism may present with palpitations, diaphoresis, tremulousness, and anxiety, it is not associated with pounding headache, is not typically episodic, and is accompanied by additional signs/symptoms such as weight loss, heat intolerance, and diarrhea. (Choice E) An insulinoma is a pancreatic tumor that secretes insulin and is associated with episodes of hypoglycemia and resultant cognitive dysfunction, palpitations, diaphoresis, and tremor. It is not associated with drug-resistant hypertension, hyperglycemia, or episodic headache. Educational objective: Pheochromocytoma is an adrenal tumor that presents with episodic headache, hypertension, tachycardia/palpitations, and diaphoresis and may be accompanied by anxiety and panic attacks. Given the risks associated with a missed medical diagnosis, physicians must maintain a high index of suspicion for underlying medical causes of psychiatric symptoms. References: Initial clinical presentation and spectrum of pheochromocytoma: a study of 94 cases from a single center. (http://www.ncbi.nlm.nih.gov/pubmed/29217652) Phaeochromocytoma and paraganglioma. (http://www.ncbi.nlm.nih.gov/pubmed/27888488)

A 44-Year-Old Woman Comes to the Office Due to Worsening