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Persistent Neutrophilia as a Preceding Symptom of Pheochromocytoma

Second Department of Internal Medicine, Hippokration Hospital, University of Athens, Athens 11527, Greece

Address correspondence to: Nikolaos Sevastos, M.D., Second Department of Internal Medicine, Hippokration Hospital, 114 Vas. Sophias, Athens 11527, Greece. E-mail: nsevast{at}med.uoa.gr.

To the editor:

Sawka et al. (1) and Kudva et al. (2) have discussed several options when testing for pheochromocytoma according to the clinical or radiological findings in each case. Furthermore, it is known that catecholamines and cortisol can provoke neutrophilia in healthy and diseased individuals (3, 4). Although a marked neutrophilia in a case of pheochromocytoma with ectopic secretion of ACTH has been described (5), this laboratory finding is not mentioned in an epidemiological study of the tumor (6). We present two cases with persistent neutrophilia as the preceding symptom of pheochromocytoma.

The first case was that of a 56-yr-old male with persistent neutrophilia for 3 yr. In a routine laboratory test, this patient was found to have an elevated white blood cell count up to 12–14 x 10⁹/liter (neutrophils, 76–80%) without any evidence of acute or chronic illness as determined by extensive work-up in two hospitalizations in tertiary hospitals. Two years later, the patient developed diabetes mellitus, and per os antidiabetic treatment with glibenclamide was started. In the subsequent 6 months, he developed two hypoglycemic episodes and antidiabetic treatment was stopped, but he developed hypertension. During the third hospitalization for further investigation, a pheochromocytoma of the right adrenal gland was found, for which the patient underwent surgery. Postoperatively, the elevated white blood cell count and glucose and blood pressure levels returned to normal.

The second patient was a 60-yr-old male who underwent extensive investigation for neutrophilia (white blood cell count, 15 x 10⁹/liter; neutrophils, 80%) in the Hematology Department, and the diagnosis of persistent neutrophilia of unknown etiology was made. Six months later, he developed paroxysmal flushing with palpitations, and pheochromocytoma of the right adrenal gland was discovered. He underwent surgical resection of the tumor, and 1 month after the operation the white blood cell count had returned to normal. In both patients, the biochemical test used for the diagnosis of pheochromocytoma was the level of 24-h urinary metanephrines and catecholamines. In such a case, a high specificity test with acceptable sensitivity (e.g. 24-h urinary metanephrines and catecholamines), as proposed by Kudva et al. (2), may be the test of choice to avoid an excessive rate of false-positive tests in this low-risk population.

It is concluded that, in a patient with persistent neutrophilia, besides the extensive search for acute or chronic disease or underlying malignancy, the diagnosis of pheochromocytoma should be excluded.

Received February 26, 2004.

References

1. Sawka AM, Jaeschke R, Singh RJ, Young Jr WF 2003 A comparison of biochemical tests for pheochromocytoma: measurement of fractionated plasma metanephrines compared with the combination of 24-hour urinary metanephrines and catecholamines. J Clin Endocrinol Metab 88:553–558[Abstract/Free Full Text]
2. Kudva YC, Sawka AM, Young WF 2003 Clinical review 164: the laboratory diagnosis of adrenal pheochromocytoma: the clinic experience. J Clin Endocrinol Metab 88:4533–4539[Free Full Text]
3. Brenner I, Shek PN, Zamecnik J, Shephard RJ 1998 Stress hormones and the immunological responses to heat and exercise. Int J Sports Med 19:130–143[Medline]
4. Brohee D, Vanhaeverbeek M, Kennes B, Neve P 1990 Leukocyte and lymphocyte subsets after a short pharmacological stress by intravenous epinephrine and hydrocortisone in healthy humans. Int J Neurosci 53:53–62[Medline]
5. Gonzalez-Villaron L, Santana S, Perez-Arellano JL, Sanchez-Sanchez R, Castro del Pozo S 1993 Pheochromocytoma with ectopic secretion of ACTH. Rev Clin Esp 193:168–171[Medline]
6. Mannelli M, Ianni L, Cilotti A, Conti A 1999 Pheochromocytomas in Italy: a multicentric retrospective study. Eur J Endocrinol 141:619–624[Abstract]

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