Livedo reticularis: a cutaneous clue to an underlying endocrine crisis. (12th April 2018)

• Record Type: Journal Article
• Authors: Shrikrishnapalasuriyar, Natasha; Noyvirt, Mirena; Evans, Philip; Gibson, Bethan; Foden, Elin; Kalhan, Atul
• Is Part Of: Endocrinology, diabetes & metabolism case reports. (2018)
• Publication Date: 2018-04-12
• Subjects: Adolescent/young adult -- Female -- White -- United Kingdom; Adrenal -- Adrenal -- Metanephrines -- Noradrenaline -- Normetanephrine -- Adrenaline -- Dopamine -- Phaeochromocytoma crisis -- Phaeochromocytoma; Breathing difficulties -- Hypertension -- Pyrexia -- Tachycardia -- Rash -- Poikiloderma -- Agitation -- Altered level of consciousness -- Sepsis -- Atrial fibrillation -- Hypotension -- CT scan -- Metanephrines (urinary) -- Echocardiogram -- White blood cell count -- C-reactive protein -- Liver function -- Kidney function -- Blood pressure -- Urea and electrolytes -- Creatinine -- C-reactive protein -- Bilirubin -- Alanine aminotransferase -- Noradrenaline -- Catecholamines (24-hour urine) -- Normetanephrine -- Adrenaline -- Dopamine -- Fluid repletion -- Amoxicillin -- Hydrocortisone -- Epinephrine -- Glucocorticoids -- Antibiotics -- Norepinephrine -- Phenoxybenzamine -- Alpha-blockers; Insight into disease pathogenesis or mechanism of therapy -- April -- 2018; Endocrinology -- Periodicals; Diabetes -- Periodicals; Diabetes Mellitus; Endocrinology; Diabetes; Endocrinology; Case Reports; Periodicals; Periodicals; 616.4
• DOI: 10.1530/EDM-17-0170
• Languages: English
• ISSNs: 2052-0573

Abstract

Abstract : A 54-year-old woman was admitted to hospital with a presumed allergic reaction to a single dose of amoxicillin given for a suspected upper respiratory tract infection. She complained of chest tightness although there was no wheeze or stridor. On examination, she was pyrexial, tachycardic, hypertensive and had a diffuse mottled rash on her lower limbs. Her initial investigations showed raised inflammatory markers. She was treated in the intensive care for a presumed anaphylactic reaction with an underlying sepsis. Further investigations including CT head and CSF examination were unremarkable; however, a CT abdomen showed a 10 cm heterogeneous right adrenal mass. Based on review by the endocrine team, a diagnosis of pheochromocytoma crisis was made, which was subsequently confirmed on 24-h urinary metanephrine measurement. An emergency adrenalectomy was considered although she was deemed unfit for surgery. Despite intensive medical management, her conditioned deteriorated and she died secondary to multi-organ failure induced by pheochromocytoma crisis. Learning points: Pheochromocytoma have relatively higher prevalence in autopsy series (0.05–1%) suggestive of a diagnosis, which is often missed. Pheochromocytoma crisis is an endocrine emergency characterized by hemodynamic instability induced by surge of catecholamines often precipitated by trauma and medications (β blockers, general anesthetic agents, ephedrine and steroids). Pheochromocytoma crisis can mimic acute coronary syndrome, cardiogenic or septic shock. Livedo reticularis can be a rare although significant cutaneous marker of underlying pheochromocytoma crisis.