Suspected Pediatric Pheochromocytoma in a Normally Hypotensive Patient: Diagnostic and Management Complexity

We report the case of a 14-year-old female with a history of orthostatic hypotension and Chiari I malformation who presented with persistent hypertension, syncope, flank pain, vomiting, and back bruising and was ultimately found to have biochemical evidence of pheochromocytoma. Evaluation revealed hypercalcemia, tachycardia, and elevated plasma and urine catecholamine metabolites. Despite the absence of classic paroxysmal symptoms, such as episodic headache, palpitations, and sweating, hypertension combined with orthostatic hypotension and elevated catecholamines raised strong suspicion for pheochromocytoma. Management involved a multidisciplinary approach, with scheduled amlodipine and labetalol effectively normalizing blood pressure and heart rate. This case underscores the importance of considering pheochromocytoma in pediatric secondary hypertension, even in the absence of hallmark symptoms, and highlights possible management of overlapping orthostatic hypotension and persistent hypertension. It also demonstrates the utility of interdisciplinary care and cautious antihypertensive management in addressing the complex presentation of pediatric pheochromocytoma.