Case #027

Hypertension that comes and goes is a different disease from hypertension that stays. Essential hypertension does not let a blood pressure fall to 128 between attacks and climb to 238 during them, and it does not resist three agents at once. Paroxysmal headache, sweating and palpitations with complete normality in between are the classic triad, and the episodic pattern is the whole point of it. The detail worth noticing is that a beta blocker made an attack worse: blocking beta-2-mediated vasodilatation in the presence of circulating catecholamines leaves alpha-mediated vasoconstriction unopposed, and this is precisely why alpha blockade must always come first. Weight loss despite good appetite reflects the hypermetabolic state, and the impaired fasting glucose comes from catecholamine-driven insulin suppression. Plasma free metanephrines are the screening test of choice because catecholamines are secreted episodically while their metabolites are produced continuously within the tumour, so a level drawn between attacks remains informative. An unenhanced attenuation above 10 Hounsfield units argues against a benign adenoma, and MIBG confirms functional chromaffin tissue. The family history of adrenal and thyroid surgery raises MEN2, which warrants RET testing and screening for medullary thyroid carcinoma before any operation. The cure is surgical, but the sequence is the examinable part. Alpha blockade with phenoxybenzamine or doxazosin is established for 10 to 14 days first, alongside liberal salt and fluid, because those cool peripheries are a chronically vasoconstricted and contracted plasma volume that will collapse the moment the vasoconstriction is taken away. Only then may a beta blocker be added for tachycardia, and never before, for the reason her own attack demonstrated. Handling the tumour releases a catecholamine surge and removing it is followed by abrupt hypotension, so both are anticipated with invasive monitoring rather than discovered.