SUN-498 Hidden Adrenal Villains: When Pheochromocytoma Meets Steroid Therapy

Abstract Disclosure: L. Arnold: None. R. Hoxhaj: None. P.D. John: None. Background: Adrenergic crises in pheochromocytoma are triggered by anesthesia induction, tumor manipulation, or medications. While glucocorticoid-induced adrenergic crises were rarely documented, they are known to be life-threatening and have been increasingly encountered in clinical settings. Increased endogenous cortisol production observed in pheochromocytomas 1 can exacerbate crises when combined with exogenous glucocorticoid exposure risking hemorrhagic adrenal bleeds, though these cases are often undiagnosed or unsuspected. We present two cases of hemorrhagic pheochromocytoma diagnosed after adrenergic crises with glucocorticoid use. Clinical Cases: Patient 1: 54-year-old male with recent glucocorticoid injection and oral prednisolone for right shoulder bursitis presented in hypertensive emergency with BP 213/144 mmHg, respiratory failure requiring intubation and acute renal failure. Imaging revealed a 6 cm right adrenal mass with hemorrhage with plasma metanephrines 40x ULN and urinary metanephrines 81x ULN. After prolonged hospital stay and stabilization, with outpatient alpha and beta blockade, he underwent a successful right adrenalectomy. Patient 2: 48-year-old female with a kidney transplant on maintenance 5 mg prednisone daily with recent history of laparoscopic appendectomy who presented with hypertensive emergency with BP 231/110 mm/Hg, NSTEMI and diabetic ketoacidosis. Imaging revealed interval enlargement of a previously known 1 cm left adrenal cyst from six years prior, now 3.4 cm with internal hemorrhage. Plasma metanephrines 4x ULN and urine metanephrines 14x ULN. Initial adrenalectomy was unsuccessful upon anesthesia induction despite conventional alpha and beta blockade, necessitating metyrosine escalation, which ultimately led to successful resection of the left adrenal nodule. Discussion: The link between glucocorticoid therapy and pheochromocytoma crisis is crucial to preventing severe complications, as glucocorticoids can elevate catecholamine production and contribute to vascular instability, increasing the risk of severe hypertension and tumor hemorrhage. Literature review over a 70-year time span of pheochromocytomas revealed that reports of glucocorticoid induced hemorrhagic pheochromocytomas is scant. In conclusion, when a patient presents with a hypertensive emergency following recent steroid exposure, clinicians, should have a high index of suspicion for hemorrhagic pheochromocytoma and initiate prompt, aggressive management. References: Constantinescu G et al. Glucocorticoid excess in patients with pheochromocytoma compared with paraganglioma and other forms of hypertension. J Clin Endocrinol Metab. 2020;105(9):e3374-83. Presentation: Sunday, July 13, 2025