Feocromocitoma adrenal gigante derecho. Reporte de un caso / Right giant adrenal pheochromocytoma. A case report

Introducción. El feocromocitoma es una neoplasia endocrina productora de catecolaminas, poco común, que generalmente se origina en la medula suprarrenal, y rara vez en el tejido cromafín extraadrenal, dándosele el nombre de paraganglioma. Existe una gran variedad de signos y síntomas secundarios a la secreción excesiva de catecolaminas por lo que su diagnóstico y tratamiento oportunos son fundamentales para evitar complicaciones potencialmente fatales. Caso clínico. Paciente femenina de 54 años, con dolor abdominal intermitente y con aumento progresivo, localizado en el cuadrante superior derecho. Por estudios imagenológicos se diagnosticó una gran masa suprarrenal derecha, con pruebas de laboratorio que encontraron niveles de metanefrinas y catecolaminas en orina normales. Discusión. Debido al tamaño del tumor y al íntimo contacto con las estructuras adyacentes, se realizó la resección por vía abierta, sin complicaciones y con una buena evolución postoperatoria. El informe anatomopatológico confirmó el diagnóstico de feocromocitoma suprarrenal derecho. Conclusión. Aunque poco frecuente, el feocromocitoma es una patología que se debe sospechar ante la presencia de masas suprarrenales y alteraciones relacionadas con la secreción elevada de catecolaminas. Se debe practicar el tratamiento quirúrgico de forma oportuna.

Introduction. Pheochromocytoma is a rare catecholamine-producing endocrine neoplasm that generally originates in the adrenal medulla, and rarely in extra-adrenal chromaffin tissue, giving it the name of paraganglioma. There is a wide variety of signs and symptoms secondary to excessive secretion of catecholamines, so its timely diagnosis and treatment are essential to avoid potentially fatal complications. Clinical case. A 54-year-old female patient with intermittent abdominal pain and progressive increase, located in the right upper quadrant. By imaging studies, a large right adrenal mass was diagnosed, with laboratory tests that found normal levels of metanephrines and catecholamines in urine. Discussion. Due to the size of the tumor and the intimate contact with the adjacent structures, the resection was performed by open approach, without complications and with a good postoperative evolution. The pathology report confirmed the diagnosis of right adrenal pheochromocytoma. Conclusion. Although rare, pheochromocytoma is a pathology that should be suspected in the presence of adrenal masses and changes related to elevated catecholamine secretion. Surgical treatment should be performed in a timely manner.

Catecholamines production by kidney tissue and mesangial cell culture is differentially modulated by diabetes / A produção de catecolaminas pelo tecido renal e a cultura de células mesangiais é modulada diferencialmente pelo diabetes

Abstract Introduction: According to the International Diabetes Federation, the number of people with diabetes mellitus may reach 700 million in 2045. Catecholamines are involved in the regulation of several kidney functions. This study investigates the effects of hyperglycemia on catecholamines' metabolism in kidney tissue from control, diabetic, and insulin-treated diabetic rats, both in vivo and in vitro. Methods: Male Wistar-Hannover rats were randomized into: control, diabetic, and insulin-treated diabetic groups. Diabetes was induced by a single injection of streptozotocin, and diabetic treated group also received insulin. After 60 days, blood and kidney tissue from all groups were collected for catecholamines' quantification and mesangial cells culture. Results: diabetic rats had lower body weight, hyperglycemia, and increase water intake and diuresis. Additionally, diabetes promoted a sharp decrease in creatinine clearance compared to control group. Regarding the whole kidney extracts, both diabetic groups (treated and non-treated) had significant reduction in norepinephrine concentration. In mesangial cell culture, catecholamines' concentration were lower in the culture medium than in the intracellular compartment for all groups. Norepinephrine, epinephrine, and dopamine medium levels were increased in the diabetic group. Conclusion: The major finding of the present study was that 8 weeks of diabetes induction altered the kidney catecholaminergic system in a very specific manner, once the production of catecholamines in the excised kidney tissue from diabetic rats was differentially modulated as compared with the production and secretion by cultured mesangial cells.

Resumo Introdução: Segundo a Federação Internacional de Diabetes, o número de pessoas com diabetes mellitus pode chegar a 700 milhões em 2045. As catecolaminas estão envolvidas na regulação de várias funções renais. Este estudo investiga os efeitos da hiperglicemia no metabolismo das catecolaminas no tecido renal de ratos controle, diabéticos e diabéticos tratados com insulina, tanto in vivo como in vitro. Métodos: Os ratos Wistar-Hannover machos foram randomizados em: grupos controle, diabéticos e diabéticos tratados com insulina. O diabetes foi induzido por uma única injeção de estreptozotocina, e o grupo diabético tratado também recebeu insulina. Após 60 dias, sangue e tecido renal dos grupos foram coletados para quantificação de catecolaminas e cultura de células mesangiais. Resultados: ratos diabéticos apresentaram peso corporal mais baixo, hiperglicemia, e aumento da ingestão de água e diurese. Ademais, o diabetes promoveu uma redução acentuada na depuração de creatinina comparado com o grupo controle. Quanto aos extratos de rim total, ambos os grupos diabéticos (tratados/não tratados) tiveram redução significativa na concentração de noradrenalina. Na cultura de células mesangiais, a concentração de catecolaminas foi menor no meio de cultura do que no compartimento intracelular para todos os grupos. Níveis médios de noradrenalina, adrenalina e dopamina estavam aumentados no grupo diabético. Conclusão: O principal achado deste estudo foi que 8 semanas de indução de diabetes alteraram o sistema catecolaminérgico renal de maneira muito específica, já que a produção de catecolaminas no tecido renal excisado de ratos diabéticos foi modulada diferencialmente comparada com produção e secreção por células mesangiais cultivadas.

Impacto cardiovascular, conducta diagnóstica y terapéutica del feocromocitoma como causa de hipertensión arterial / Cardiovascular impact, diagnostic and therapeutic management of pheochromocytoma as a cause of arterial hypertension

INTRODUCCIÓN. Los feocromocitomas son tumores que provienen de las células neuroendócrinas de la médula adrenal y producen alta secreción de catecolaminas. Generan complicaciones cardiovasculares graves que suelen asociarse con crisis hipertensivas. Es importante valorar el impacto cardiovascular de esta entidad. OBJETIVO. Realizar una revisión exhaustiva de las diversas manifestaciones de los feocromocitomas como causa de hipertensión arterial, su impacto cardiovascular, conducta diagnóstica y terapéutica. MATERIALES Y MÉTODOS. Revisión bibliográfica y análisis de 141 artículos científicos que incluyeron temas sobre el impacto cardiovascular, conducta diagnóstica y terapéutica del feocromocitoma como causa de hipertensión arterial. Se usó bases de datos: Medline, Embase, Scopus, Pubmed, Google Académico. Criterios de búsqueda en DECS, MeSH: "pheochromocytoma OR hypertension arterial AND cardiomyopathy", en inglés- español. Fueron seleccionados: 13 publicaciones de texto completo, 10 artículos retrospectivos, 2 guías de práctica clínica y 1 revisión. Se excluyeron 128 artículos científicos. RESULTADOS. Se realizó una revisión de las manifestaciones clínicas de los feocromocitomas como causa de hipertensión arterial y el impacto cardiovascular se relacionó con la producción de catecolaminas. Para el diagnóstico, la sensibilidad de la resonancia magnética es del 93-100%; la especificidad de resonancia magnética o tomografía computarizada en combinación con gammagrafía con metayodobencilguanidina con 123I es cercana al 100%. La resección del feocromocitoma tiene potencial curativo. CONCLUSIÓN. Los feocromocitomas presentan variabilidad clínica, se asocian a complicaciones cardiovasculares y cerebrovasculares graves por producción de catecolaminas. El diagnóstico oportuno y eficaz debe realizarse mediante resonancia magnética y gammagrafía en caso de alta sospecha clínica. El tratamiento quirúrgico es de elección.

INTRODUCTION. Pheochromocytomas are tumors arising from the neuroendocrine cells of the adrenal medulla and produce high secretion of catecholamines. They generate severe cardiovascular complications that are often associated with hypertensive crises. It is important to assess the cardiovascular impact of this entity. OBJECTIVE. To perform an exhaustive review of the various manifestations of pheochromocytomas as a cause of arterial hypertension, their cardiovascular impact, diagnostic and therapeutic conduct. MATERIALS AND METHODS. Bibliographic review and analysis of 141 scientific articles that included topics on the cardiovascular impact, diagnostic and therapeutic behavior of pheochromocytoma as a cause of arterial hypertension. The following databases were used: Medline, Embase, Scopus, Pubmed, Google Scholar. Search criteria in DECS, MeSH: "pheochromocytoma OR hypertension arterial AND cardiomyopathy", in English-Spanish. The following were selected: 13 full-text publications, 10 retrospective articles, 2 clinical practice guidelines, and 1 review. A total of 128 scientific articles were excluded. RESULTS. A review of the clinical manifestations of pheochromocytoma as a cause of arterial hypertension was performed and the cardiovascular impact was related to catecholamine production. For diagnosis, the sensitivity of MRI is 93-100%; the specificity of MRI or computed tomography in combination with 123I-methiodobenzylguanidine scintigraphy is close to 100%. Resection of pheochromocytoma has curative potential. CONCLUSION. Pheochromocytomas present clinical variability, are associated with severe cardiovascular and cerebrovascular complications due to catecholamine production. Timely and effective diagnosis should be made by MRI and scintigraphy in case of high clinical suspicion. Surgical treatment is the treatment of choice.

Perioperative management of pheocromocytoma/paraganglioma: a comprehensive review / Manejo perioperatorio del feocromocitoma/ paraganglioma: una revisión exhaustiva

Abstract Pheochromocytomas are rare neuroendocrine neoplasms that require adequate preoperative evaluation in order to prevent and lessen the serious complications of catecholamine hypersecretion. Preoperative management contributes to reducing morbidity and mortality rates in patients who have not been diagnosed with this condition and undergo any surgery. However, current mortality seems to be lower, a fact attributed to preoperative management with alpha blockers.

Resumen Los feocromocitomas son neoplasias neuroendocrinas poco frecuentes que requieren una evaluación preoperatoria adecuada, con el fin de prevenir y disminuir las complicaciones graves de la hipersecreción de catecolaminas. El manejo preoperatorio contribuye a disminuir las tasas de morbimortalidad en los pacientes que no han sido diagnosticados con esta entidad y son sometidos a cualquier cirugía. Sin embargo, la mortalidad actual parece ser más baja, hecho atribuido a un manejo preoperatorio con α-bloqueadores.

Feocromocitoma y Paraganglioma: un reto más allá de la clínica / Pheochromocytoma and Paraganglioma: a Challenge beyond the Clinic

Resumen Los feocromocitomas y paragangliomas son tumores raros que se originan en las células cromafines. Tienen un amplio espectro clínico que va desde el hallazgo incidental hasta manifestaciones por la producción exagerada de catecolaminas. El diagnóstico bioquímico se realiza mediante medición de metanefrinas libres en plasma. El tratamiento ideal es la escisión quirúrgica completa previo bloqueo de receptores a y 6 adrenérgicos. En caso de enfermedad metastásica, las opciones de tratamiento sistêmico actuales son limitadas y con escasa tasa de respuesta. Está en investigación el uso de antiangiogénicos.

Abstract Pheochromocytomas and Paragangliomas are rare tumors, originated from the chromaffin cells. They have a broad clinical spectrum from incidental finding to full clinical manifestations explain to overproduction of catecholamines. The biochemistry diagnosis is made by the measurement of free Metanephrines in plasma. Complete surgical removal is the optimal treatment, previously having a y 6 adrenergic receptors blockage. In case of metastasic disease, treatment options are palliative, limited and with a low rate response; the use of antiangiogenic treatments is under investigation.

Feocromocitoma: relato de caso / Pheochromocytoma: case report

Pheochromocytomas are tumors of chromaffin cells in the adrenal medulla that produce, store, metabolize, and secrete catecholamines. Due to increased secretion the patient may present with various symptoms, but elevation of blood pressure is the most common manifestation, and can cause serious complications if not recognized and treated in time. The present report mentions a case of a young male patient who started the picture with severe hypertension, tachycardia and headache, diagnosed with Pheochromocytoma during the investigation of paroxysmal arterial hypertension. It should be noted that early diagnosis, followed by surgical treatment of tumor removal, makes it possible to cure the disease and remission of symptoms.

Os feocromocitomas são tumores das células cromafins da medula adrenal que produzem, armazenam, metabolizam e secretam catecolaminas. Devido à secreção aumentada, o paciente pode apresentar vários sintomas, porém a elevação da pressão arterial é a manifestação mais comum e pode causar sérias complicações se não for reconhecida e tratada a tempo. O presente relato menciona o caso de paciente do sexo masculino, jovem, com início de quadro com hipertensão severa, taquicardia e cefaleia, sendo diagnosticado com feocromocitoma durante a investigação do quadro de hipertensão arterial paroxística. Ressalva-se que o diagnóstico precoce seguido do tratamento cirúrgico de retirada do tumor possibilita a cura da patologia e a remissão dos sintomas.

Clevidipine as an antihypertensive drug in three pheochromocytoma surgeries: Case series / Clevidipino como fármaco antihipertensivo en tres cirugías de feocromocitoma: Serie de casos

Abstract Introduction Laparoscopic adrenalectomy is the treatment of choice of pheochromocytoma. During the first surgical phase (pneumoperitoneum insufflation, tumor and veins handling), there is a risk of hypertensive crisis due to catecholamine release. After tumor excision, patients can suffer relative vasodilation and the residual effect of antihypertensive drugs, which results in arterial hypotension. For that reason, antihypertensive drugs used in the first phase should have a rapid onset of action, short half-life and no residual effect. Methods We report a series of three cases of patients with pheochromocytoma who were treated with laparoscopic adrenalectomy. They all received clevidipine infusion from the beginning of the surgery, before they had presented hypertension, to treat and try to minimize hypertensive peaks. Results In all patients, hypertensive peaks were controlled in a few minutes. After tumor resection, clevidipine infusion was stopped in all cases, and any patient required infusion of vasopressors. Discussion Clevidipine could be a first choice antihypertensive drug in pheochromocytoma surgery. Starting the infusion of clevidipine before the hypertensive peaks could help to make them less pronounced.

Resumen Introducción La adrenalectomía laparoscópica es el tratamiento de elección del feocromocitoma. Durante la primera fase quirúrgica (insuflación de neumoperitoneo, manipulación del tumor y de las venas implicadas), existe el riesgo de que se desencadenen crisis hipertensivas debido a la liberación de catecolaminas. Después de la extirpación del tumor, los pacientes pueden sufrir una vasodilatación relativa y el efecto residual de los fármacos antihipertensivos usados previamente, lo que resulta en hipotensión arterial. Por esa razón, los fármacos antihipertensivos utilizados en la primera fase quirúrgica deben tener rápido inicio de acción, vida media corta y mínimo efecto residual. Métodos Se describe una serie de casos de tres pacientes con feocromocitoma que fueron tratados con adrenalectomía laparoscópica. Todos recibieron infusión de clevidipino desde el comienzo de la cirugía, antes de presentar hipertensión arterial, para así intentar minimizar y tratar rápidamente los posibles picos hipertensivos. Resultados En todos los pacientes los picos hipertensivos se controlaron en pocos minutos. Después de la resección del tumor, la infusión de clevidipino se detuvo en todos los casos y ningún paciente requirió perfusión de vasopresores. Discusión El clevidipino podría ser un fármaco antihipertensivo de primera elección en la cirugía de feocromocitoma. Iniciarlo antes de que ocurran los picos hipertensivos podría ayudar a que sean más leves.

Crisis adrenérgica como forma de debut de un neuroblastoma / Adrenergic crisis as a debut form of a neuroblastoma

INTRODUCCIÓN: La forma clínica de presentación más común del neuroblastoma es el de una masa abdominal, pero puede presentarse con sintomatología menos habitual, como es la crisis adrenérgica por liberación de catecolaminas. OBJETIVO: Describir una forma de presentación inusual de neuroblastoma y el amplio diagnóstico diferencial que existe en un lactante con síntomas adrenérgicos. CASO CLÍNICO: Lactante femenina de 7 semanas de vida, consultó por historia de tres semanas de sudoración e irritabilidad a lo que se asoció fiebre de 24 h de evolución y dificultad respiratoria. Al ingreso presentaba mal esta do general, irritabilidad, sudoración, enrojecimiento facial, taquipnea y palidez cutánea, taquicardia sinusal extrema e hipertensión arterial (HTA), interpretadas como sintomatología adrenérgica. Se completó el estudio con una ecografía abdominal y resonancia magnética que mostraron una gran masa retroperitoneal compatible con neuroblastoma. Las catecolaminas en sangre y en orina mostraron altos niveles de dopamina, adrenalina y noradrenalina, probablemente de origen tumoral. Se inició tratamiento antihipertensivo con fármacos alfa bloqueantes con buen control de la tensión arterial. Se resecó quirúrgicamente el tumor sin incidencias y con una adecuada recuperación posterior. La paciente presentó evolución favorable a tres años de seguimiento. CONCLUSIONES: en un lactante con sintomatología adrenérgica como irritabilidad, enrojecimiento, sudoración asociada a HTA, se debe descartar patología cardiaca, metabólica (hipoglucemia), intoxicaciones y/o patología suprarrenal. Dentro de esta última, el neuroblastoma es la primera posibilidad diagnóstica, por ser uno de los principales tumores en la infancia y aunque esta presentación no es habitual puede producir estos síntomas.

INTRODUCTION: The most common clinical presentation of neuroblastoma is an abdominal mass, but it can present with uncommon symptoms, such as adrenergic storm due to catecholamine release. OBJECTIVE: To describe an unusual presentation of neuroblastoma and the wide differential diagnosis that exists in an infant with adrenergic symptoms. CLINICAL CASE: A 7-week old female infant was evaluated due to a 3-week history of sweating and irritability associated with a 24-hour fever and respiratory distress. At admission, she presented poor general condition, irritability, sweating, facial redness, tachypnea and skin paleness, extreme sinus tachycardia, and high blood pressure (HBP), interpreted as adrenergic symptoms. The study was completed with abdominal ultrasound and magnetic reso nance imaging that showed a large retroperitoneal mass compatible with neuroblastoma. Plasma and urinary catecholamines tests showed high levels of dopamine, adrenaline, and noradrenaline, probably of tumor origin. We started antihypertensive treatment with alpha-blocker drugs, showing a good blood pressure control. The tumor was surgically resected without incidents and adequate subsequent recovery. The patient presented a favorable evolution after three years of follow-up. CONCLUSIONS: In an infant with adrenergic symptoms such as irritability, redness, sweating associated with HBP, it should be ruled out pathology heart or metabolic (hypoglycemia) pathology, intoxications, and/or adrenal pathology. Within this last one, neuroblastoma is the first diagnostic possibility, since it is one of the main tumors in childhood and, although this presentation is not usual, it can produce these symptoms.

Involvement of catecholamines in the myocardium of rats submitted to experimental model of portal hypertension / Envolvimento das catecolaminas no miocárdio de ratos submetidos a modelo experimental de hipertensão portal

ABSTRACT Background: The role of autonomic nervous system in the development and maintenance of portal hypertension is not fully elucidated. It is known that the gene expression of norepinephrine in the superior mesenteric artery varies with time, and it may contribute for splanchnic vasodilation and its consequent hemodynamic repercussions. It is still not known exactly how the adrenergic expression behaves at the heart level in the initial stages of this process. Aim: To evaluate the immunohistochemical expression of the enzyme tyrosine hydroxylase (tyrosine 3-monooxygenase), involved in the synthesis of norepinephrine, in the myocardium of rats submitted to partial ligation of the portal vein. Methods: Twenty-four Wistar rats were divided into two groups: Sham Operated and Portal Hypertension. The partial ligation was performed in the Portal Hypertension group, and after 1/6/24 h and 3/5/14 days the animals were euthanized. Immunohistochemical analysis was performed to quantify the expression of the stained enzyme using the ImageJ program. Results: The Portal Hypertension group expressed percentages between 4.6-6% of the marked area, while the Sham Operated group varied between 4-5%. Although there was no statistical significance, the percentage stained in the Portal Hypertension group followed an increasing pattern in the first 6 h and a decreasing pattern after 24 h, which was not observed in the Sham Operated group. Conclusion: The expression of noradrenaline in rat myocardium during the first two weeks after partial ligation of the portal vein, with tyrosine hydroxylase as marker, did not show differences between groups over time.

RESUMO Racional: O papel do sistema nervoso autônomo na hipertensão portal não está completamente elucidado. Sabe-se que, nessa condição, a expressão gênica da norepinefrina na artéria mesentérica superior modifica-se com o tempo, podendo ser importante contribuinte para a vasodilatação esplâncnica e suas repercussões hemodinâmicas. Apesar dos estudos sobre as repercussões cardiovasculares na hipertensão portal, ainda não se sabe como a expressão adrenérgica se comporta a nível cardíaco nas etapas iniciais desse processo. Objetivo: Avaliar a expressão imunoistoquímica da enzima tirosina hidroxilase (tirosina 3-mono-oxigenase), relacionada à síntese da norepinefrina, no miocárdio de ratos submetidos à ligadura parcial da veia porta. Métodos: Foram utilizados 24 ratos, distribuídos em dois grupos: Sham Operated e Hipertensão Portal. A ligadura parcial da veia porta foi realizada apenas no grupo Hipertensão Portal e, após 1/6/24 h e 3/5/14 dias, os animais foram eutanasiados. Foi feita a análise imunoistoquímica para quantificar a expressão da enzima corada, utilizando o programa ImageJ. Resultados: No grupo Hipertensão Portal, o miocárdio expressou percentuais entre 4,6-6% de área marcada, enquanto que no grupo Sham Operated variou entre 4-5%, sem significância estatística. Apenas no grupo Hipertensão Portal, a porcentagem corada pela enzima seguiu padrão crescente nas primeiras 6 h e decrescente após 24 h. Conclusão: A expressão da noradrenalina no miocárdio de ratos durante as primeiras duas semanas após a ligadura parcial da veia porta, tendo como marcador a enzima tirosina hidroxilase, não apresentou diferenças entre grupos ao longo do tempo.

Síndrome del corazón roto y estrés agudo / A propósito de un caso

Resumen Introducción: El estrés se ha asociado con un síndrome de insuficiencia cardiaca aguda, con morbilidad y mortalidad importantes. Metodología: Reporte de caso y revisión no sistemática de la literatura relevante. Presentación del caso: Mujer de 65 arios con antecedente de trastorno de ansiedad generalizada no tratado que, tras la muerte violenta de un hijo, sufría dolor opresivo en el precordio, el cuello y la extremidad superior izquierda que duraba más de 30 min; la sospecha clínica inicial fue síndrome coronario agudo. Revisión de la literatura: La miocardiopatía de tako-tsubo se caracteriza por disfunción ventricular izquierda, reversible en la mayoría de los casos, y alteraciones del movimiento de la pared ventricular sin anormalidades coronarias, asociado a altas concentraciones plasmáticas de catecolaminas, que en la mayoría de los casos coinciden con un estresor agudo de tipo físico o emocional. Conclusiones: La miocardiopatía de tako-tsubo es un diagnóstico diferencial que los médicos que atienden a pacientes con sospecha de síndrome coronario deben considerar, especialmente ante mujeres posmenopáusicas con antecedentes de comorbilidades psiquiátricas como el trastorno de ansiedad generalizada.

Abstract Introduction: Stress has been associated with an acute heart failure syndrome of important morbidity and mortality. Methods: Case report and non-systematic review of the relevant literature. Case presentation: A 65-year-old woman with a history of an untreated generalized anxiety disorder, whom after the violent death of her son presented with oppressive chest pain irradiated to neck and left superior extremity, lasting for more than 30 minutes, initial clinical suspect suggests acute coronary syndrome. Literature review: Tako-tsubo cardiomyopathy is characterized by a reversible left ventricular dysfunction and wall movement abnormalities, without any compromise of the coronary arteries, associated to high plasma levels of catecholamines which in most cases correlates with an acute stress of emotional or physical type. Conclusions: Tako-tsubo cardiomyopathy has to be considered by physicians among the differential diagnosis when facing patient with suspected acute coronary syndrome, especially in postmenopausal women with a history of psychiatric comorbidities such as a generalized anxiety disorder.

Feocromocitoma quístico gigante: reporte de un caso / Pheochromocytoma giant cystic: a case report

El feocromocitoma quístico gigante es tumor adrenal raro en el que predomina el curso asintomático; por lo que muchos de los casos no son diagnosticados hasta el momento de la cirugía. La simple movilización del tumor se asocia con el paso a la sangre de grandes cantidades de catecolaminas y a una elevada morbimortalidad.; por esta razón la cirugía per se y su manejo perioperatorio constituyen un enorme desafío. En este artículo se presenta el caso de un feocromocitoma gigante maligno (35 cm) que ocupaba todo el hemiabdomen derecho. Aun con el diagnóstico preoperatorio de feocromocitoma, el bloqueo farmacológico preoperatorio y las medidas intraoperatorias, el paciente falleció poco antes de que finalizara la cirugía.

The giant cystic pheochromocytoma is a rare adrenal tumor in the predominantly asymptomatic course; so many cases are not diagnosed until the time of surgery. The simple mobilization of the tumor is associated with the passage to the blood of large amounts of catecholamines and high morbidity and mortality. So the surgery itself and perioperative management are a huge challenge. This article describes the case of a malignant giant pheochromocytoma (35 cm) which occupied the entire right abdomen. Even with the preoperative diagnosis of pheochromocytoma, pharmacological blockade preoperative and intraoperative measures, the patient died shortly before the end of surgery.

Miocardiopatía de Tako-Tsubo: una manifestación inusual de feocromocitoma / Takotsubo cardiomyopathy: rare manifestation of pheochromocytoma

Takotsubo cardiomyopathy (MTT) is an acute ventricular dysfunction and reversible in absence of coronary disease. It is a rare presentation of pheochromocytoma and paraganglioma (FPGL). It was described for the first time in 1990 by Sato et al, the physiopathology is not clear yet. It is associated with high levels of catecholamines, vasospasm in the micro vascularization, rupture of atheromatous plaque and myiocarditis. The clinical presentation is similar to an acute myocardial infarction because of that the FPGL must be considered in patients without obstructive coronary lesions. We present a case of a 50 years old women with history of Arterial Hypertension, active smoking and Neurofibromatosis, who is admitted to emergency room with an acute myocardial pain.

Caracterização dos pacientes em uso de drogas vasoativas internados em unidade de terapia intensiva / Caracterización de los pacientes en uso de drogas vasoactivas internados en unidad de cuidados intensivos / Patients’ characterization in use of vasoactive drugs hospitalized in intensive care unit

Caracterizar o paciente internado em Unidade de Terapia Intensiva (UTI) em uso de drogas vasoativas (DVA). Métodos: estudo descritivo, retrospectivo, abordagem quantitativa, com 85 pacientes internados na UTI de um hospital municipal, em Fortaleza-Ceará. Coleta dos dados realizada em março e abril de 2011 pela consulta ao relatório de enfermagem. Resultados: 55,3% eram do sexo feminino, com média de idade de 70 anos. O diagnóstico mais comum foi o acidente vascular encefálico (29,4%), seguido das pneumopatias (23,5%); 89,4% necessitaram de suporte ventilatório invasivo, 98,9% usaram sonda nasogástrica, 92,9% sonda vesical de demora, 92,9 % utilizaram acesso venoso central e 90,6% fizeram uso de antibióticos. Quanto aos níveis pressóricos, apenas 4,9% apresentaram normalidade; a noradrenalina foi a DVA mais utilizada (67,1%), seguida da dopamina (35,3%); 64,7% evoluíram para óbito. Conclusão: o paciente grave apresenta especificidades que exigem conhecimento da equipe de enfermagem para uma assistência de qualidade...

Caracterizar a los pacientes hospitalizados en Unidad de Cuidados Intensivos (UCI) que hacían uso de DV. Métodos: estudio descriptivo retrospectivo, cuantitativo, con 85 pacientes ingresados en la UCI de un hospital municipal, en Fortaleza, Ceará. Recolección de datos realizada en marzo y abril de 2011 consultando a los informes de enfermería. Resultados: prevaleció el sexo femenino (55,3%) y media de edad de 70 años. El diagnóstico más frecuente fue accidente cerebrovascular (29,4%), seguido por neumopatías (23,5%); 89,4% requirieron ventilación mecánica invasiva, 98,9% utilizó sonda nasogástrica y 92,9% catéter urinario; 92,9% utilizó el acceso venoso central y el 90,6% tomaba antibióticos. En cuanto a la presión arterial, sólo el 4,9% la tenían normal, siendo la noradrenalina la DV más utilizada (67,1%), seguido por la dopamina (35,3%); 64,7% fallecieron. Conclusión: el paciente grave presenta particularidades importantes que exigen el conocimiento del equipo de enfermería para prestar asistencia de calidad...

To characterize the patients hospitalized in the intensive care unit (ICU) in the use of vasoactive drugs (VAD). Method: a retrospective study with a quantitative approach. The sample is comprised by 85patients admitted to the ICU of a municipal hospital, in Fortaleza, Ceará. Data collection was conducted in March and April 2011 through consultation of the nursing report. Results: prevalence of female patients (55.3%), with age average of 70 years. The most common diagnosis was stroke (29.4%), followed by lung disease (23.5%). It is note worthy that 89.4% required invasive mechanical ventilation, 98.9% used a nasogastric tube and 92.9% an urinary catheter, 92.9% used central venous access and 90.6% had antibiotic treatments. Regarding blood pressure, only 4.9% showed normal readings; noradrenaline was the most used VAD (67.1%), followed by dopamine (35.3%). Regarding evolution, 64.7% patients died. Conclusion: the patient in severe condition shows specificities in care that require particular knowledge of the nursing staff, in order to achieve a quality assistance...

Manifestaciones inusuales del feocromocitoma: Reporte de caso y revisión de la literatura / Unusual manifestations of phaeochromocytoma: A case report and a review of the literature

El feocromocitoma es un tumor de baja prevalencia que se origina en las células cromafines de la médula de las glándulas suprarrenales. Estos tumores como el tejido simpático normal se originan del neuroectodermo. La tríada clásica de presentación clínica es: hipertensión que puede ser persistente, paroxística o fluctuante, cefalea grave pulsátil acompañada de náuseas y/o vómito y palpitaciones con taquicardia o bradicardia refleja; pero también se pueden presentar un gran número de síntomas debido al exceso de catecolaminas plasmáticas, llegando incluso a producir un síndrome coronario agudo. Su diagnóstico se realiza por medio de la clínica (para la cual se requiere un alto grado de sospecha), el laboratorio y la imagenología. El tratamiento de elección es la resección quirúrgica del tumor por laparoscopia o cirugía abierta.

A phaeochromocytoma is a tumour of low prevalence that originates in the chromaffin cells of the medulla of the adrenal glands. These tumours, like normal sympathetic tissue, originate from neuroectoderm. The classic triad of clinical findings are: hypertension that can be persistent, paroxysmal or fluctuating, severe throbbing headache accompanied by nausea and/or vomiting, and palpitations with tachycardia or reflex bradycardia. It can also present with a myriad of symptoms due to the excess of plasma catecholamines, even producing an acute coronary syndrome. Diagnosis is made through the clinical (for which requires a high degree of suspicion), laboratory, and imaging findings. The treatment is surgical resection of the tumour by laparoscopy or open surgery.

Síndrome coronario agudo con supradesnivel del ST asociado al feocromocitoma con las catecolaminas inicialmente normales / Acute coronary syndrome with ST elevation associated with pheochromocytoma with initially normal catecholamine values

Los feocromocitomas son tumores secretores de catecolaminas que cursan con paroxismos de hipertensión o hipotensión arterial y palpitaciones. Son una causa rara del síndrome coronario agudo. Presentamos el caso de una paciente con síndrome coronario agudo secundario a feocromocitoma que inicialmente tenía valores normales de catecolaminas.

Pheochromocytomas are catecholamine-secreting tumors that involve paroxysmal hypertension or hypotension and palpitations. They are a rare cause of acute coronary syndrome. We present the case of a patient with acute coronary syndrome secondary to a pheochromocytoma with initially normal catecholamine values.

Feocromocitoma e gravidez: Relato de caso e revisão atualizada / Pheochromocytoma and pregnancy: A case report and review

Resumo O feocromocitoma é um tumor da adrenal produtor de catecolaminas, sendo causa rara de hipertensão arterial na gravidez. Sua prevalência em hipertensos é de 0,2%, e em 0,002% das gestações. Acompanhamos gestante hipertensa de 24 anos, branca, tercigesta, admitida na 33ª semana com emergência hipertensiva, indicada cesárea devido a sofrimento fetal, evoluindo com edema agudo de pulmão no pós-parto imediato. Submetida à videolaparoscopia após 13 dias por dor abdominal aguda, sem achado significativo. No pós-operatório, devido à hipertensão arterial grave e refratária, suspeitou-se de feocromocitoma, confirmado por exames bioquímicos e de imagem. Realizada adrenelectomia unilateral com cura da hipertensão. A anatomia patológica e a imunohistoquímica confirmaram o diagnóstico. Concluímos que casos atípicos de hipertensão na gravidez devem ser precocemente investigados e diferenciados da pré-eclâmpsia. Apesar da baixa prevalência, o feocromocitoma na gravidez aumenta consideravelmente a morbimortalidade materno-fetal e o seu reconhecimento e tratamento precoces mudam drasticamente o seu desfecho.

Abstract Pheochromocytoma is a catecholamine-producing adrenal tumor, being a rare cause of hypertension in pregnancy. It's prevalence in hypertensive patients is 0.2%, and 0.002% of pregnancies. We follow hypertensive pregnant 24 year old on her third pregnancy, admitted to 33 weeks with hypertensive emergency cesarean section indicated by fetal distress evolving with acute pulmonary edema in the post-partum period. Indicated laparoscopy after 13 days for acute abdominal pain, with no significant finding. In the postoperative, due a severe and resistant hypertension, suspected of pheochromocytoma and confirmed by biochemical tests and imaging. Performed unilateral adrenelectomia with cure of hypertension. The pathology and immunohistochemistry confirmed the diagnosis. We conclude that atypical cases of hypertension in pregnancy should be investigated early and differentiated pre-eclampsia. Despite the low prevalence, pheochromocytoma in pregnancy increases fetal maternal morbidity and mortality and the early recognition and treatment drastically change their outcome.

Acción de Lachesis trigonocephalus en diferentes potencias sobre las catecolaminas cerebrales / Lachesis trigonocephalus action in different potencies on brain catecholamines

Durante el Congreso Internacional del Centenario de la Escuela Libre de Homeopatía de México, celebrado en 2012, la doctora Josefina Sánchez Reséndiz presentó esta ponencia para hablar de los beneficios que la salud femenina puede tener gracias al uso de algunos medicamentos homeopáticos, en especial Lachesis trigonocephalus. De manera breve y precisa, la doctora Sánchez Reséndiz recordó los resultados de las investigaciones que realizó con el doctor Ángel Lerdo de Tejada y colaboradores sobre las catecolaminas cerebrales, partiendo de que la dopamina cerebral, a nivel del hipotálamo, tiene una gran influencia en la hormona luteinizante y en la conducta. Se pudo observar que el medicamento homeopático Lachesis trigonocephalus, a diferentes potencias, puede generar modificaciones estadísticamente significativas en las catecolaminas cerebrales, mecanismo por el cual, su uso podría ser capaz de mejorar los síntomas de la mujer durante el climaterio y la menopausia...

During the International Congress, in the 100th aniversary of the Escuela Libre de Homeopatía in Mexico, held in 2012, Josefina Sanchez Resendiz MD presented this conference to discuss about women’s health benefits that can be obtained by the use of some homeopathic medicines, especially Lachesis trigonocephalus. In a brief and precise way, Dr. Sanchez Resendiz recalled the results of the research conducted with Angel Lerdo de Tejada MD and collaborators on brain catecholamines, since brain dopamine in the hypothalamus, has a great influence in the luteinizing hormone its behavior. She observed that different potencies of the homeopathic remedy Lachesis trigonocephalus, can generate statistically significant changes in brain catecholamines. This could explain why its use may improve women’s symptoms during perimenopause and menopause...

Cardiomiopatía de Takotsubo en un paciente con paraganglioma torácico funcional / Takotsubo cardiomyopathy in a patient with functional thoracic paraganglioma

La cardiomiopatía de Takotsubo sigue siendo una entidad nosológica subdiagnosticada a causa de su variada presentación clínica. Esta patología tiene predilección por el sexo femenino; se manifiesta como una disfunción del ventrículo izquierdo desencadenada por un evento agudo de estrés; tiene la particularidad de ser un proceso reversible. La incidencia de paraganglioma es de menos del 1% de los tumores intratorácicos, y su relación con la génesis de cardiomiopatía de Takotsubo está más que demostrada, aunque es una causa poco frecuente de esta. Se reporta caso clínico de una paciente femenina de 43 años con cardiomiopatía de Takotsubo secundaria a un paraganglioma intratorácico funcional.

Takotsubo’s cardiomyopathyis a clinical condition usually misdiagnosed due to its diverse clinical signs and symptoms. This pathologyis frequently found in women; the clinical picture is related to a left-ventricledys function triggered by an event of severe stress. It is a reversible process. The incidence of paraganglioma is less than 1% of intrathoracic tumors and, even if not a common cause, its relation with the pathophysiology of Takotsubo’s cardiomyopathy is well established. We report the case of a 43 year-old female, which presented a Takotsubo’s cardiomyopathy in the context of an intra-thoracic functional paraganglioma.