A case of phaeochromocytoma mimicking an acute ischemic limb: an unusual presentation

Case: A 43-year-old Caucasian lady presented with an acutely painful, cold left leg to the vascular surgeons. She was being treated for respiratory tract infection in the community. She has been investigated for palpitations 7 years ago with no cause identified and headache 3 years ago with normal CT head. Her peripheral vascular examination was unremarkable, including a normal ankle brachial pressure index. She was admitted for further investigations to rule out an underlying ischemic pathology. She later went into respiratory peri-arrest and was subsequently intubated. Chest radiograph demonstrated acute respiratory distress syndrome, arterial blood gas analysis showed Type 1 respiratory failure. She required inotropic support in Intensive Care Unit. CT pulmonary angiogram was negative for pulmonary embolism but demonstrated an incidental 7 cm left sided adrenal mass. No other lesions were identified on the CT of thorax, abdomen and pelvis. An echocardiogram showed an ejection fraction of 25% with a dilated left ventricle. The urinary catecholamines, which were sent earlier in view of her labile blood pressure came back grossly elevated. The total urinary metadrenaline level was 51 umol/coll (0.00–2.00) and normetadrenaline level was 33 umol/coll. (0.00–4.90).