Pheo-Nominal Finds: Using Point-of-Care Ultrasonography (POCUS) to Detect Hemorrhagic Postpartum Pheochromocytoma

Introduction: Pheochromocytoma is a rare neuroendocrine tumor originating from the adrenal medulla with an estimated prevalence of 1 in 2,500. Peripartum pheochromocytoma is even rarer, occurring in 1 in 50,000 pregnancies. Prompt diagnosis and treatment are essential given high mortality and cardiovascular risks; however, diagnosis is often delayed due to nonspecific presentation. Point-of-care ultrasound (POCUS) can be an invaluable tool in expediting the diagnosis of postpartum pheochromocytoma. Case Description: A 34-year-old, 2-month postpartum female presented for evaluation of suspected preeclampsia. She reported severe intermittent headache and labile home blood pressure despite treatment with labetalol. Initial assessment suggested preeclampsia and reversible cerebral vasoconstriction syndrome, yet brain MRI showed no anomalies. POCUS was performed for workup of secondary hypertension and revealed a 8.86 x 6.88 cm complex heterogeneous mass abutting the right kidney, raising concern for pheochromocytoma. MRI redemonstrated a large hemorrhagic adrenal mass, and serum normetanephrine levels (3305.7 pg/mL) confirmed the diagnosis. The patient was switched to an alpha blockade and promptly underwent adrenalectomy with resolution of symptoms and hypertension. Discussion: Pheochromocytoma, while rare, must be considered in cases of suspected secondary hypertension, particularly in pregnant patients. Diagnosis is made by urine or serum metanephrine levels and imaging, specifically CT or MRI. However, diagnosis can be challenging due to rarity and nonspecific presentation with varied symptoms. Diagnostic delays can lead to prolonged symptom burden, psychologic stress, and a 27-fold increased risk of gestational complications for patients. POCUS offers a key diagnostic adjunct to rapidly screen for adrenal masses and potentially decrease time-to-treatment of pheochromocytoma.