Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

ABSTRACT INTRODUCTION Pheochromocytomas and paragangliomas are rare neuroendocrine tumors that secrete catecholamines. Symptoms of these tumors are related directly to catecholamine excess but can be intermittent and easily misattributed to other more common pathologies.  Identification in the Emergency Department is inherently difficult.  In the COVID-19 pandemic physicians have had to account for both the disease itself as well as associated increased prevalence of cardiac, pulmonary, and vascular complications. Such shifting of disease prevalence arguably makes rarer diseases, like pheochromocytoma, less likely to be recognized. CASE REPORT We report a case of pheochromocytoma discovered in the emergency department in a patient who presented with fatigue, tachycardia, and diaphoresis. The differential included pulmonary embolism, cardiomyopathy, congestive heart failure and infectious causes.  A broad workup was begun including serology, electrocardiogram, Computed Tomography Angiogram (CTA), and COVID-19 testing. This patient was evaluated in the winter of 2020, the local height of the COVID-19 pandemic, and was found to be positive.  A tiny retroperitoneal tumor was reported on CTA as “incidental” in the setting of multifocal pneumonia from COVID-19 infection. But further history taking discovered many years of intermittent symptoms and suggested that the tumor may be more contributory to the patient’s presentation. Subsequent MRI and surgical pathology confirmed the pheochromocytoma. CONCLUSION This case presentation highlights the importance of careful history taking, keeping a broad differential, and examining incidental findings in the context of the patient’s presentation.