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The patient had a pheochromocytoma. This tumor secretes cat-echolamines, especially norepinephrine and epinephrine, result-ing in increases in blood pressure (via α1 receptors) and heart rate (via β1 receptors). The pheochromocytoma was in the left adrenal gland and was identified by meta-iodobenzylguanidine (MIBG) imaging, which labels tissues that have norepinephrine transporters on their cell surface (see text). In addition, he had elevated plasma and urinary norepinephrine, epinephrine, and their metabolites, normetanephrine and metanephrine. The catecholamines made the blood pressure surge and the heart rate increase, producing a typical episode during the examina-tion, perhaps set off in this case by external pressure as the phy-sician palpated the abdomen. His profuse sweating was typical and partly due to α1 receptors, although the large magnitude of drenching sweats in pheochromocytoma has never been fully explained. Treatment would consist of preoperative pharma-cologic control of blood pressure and normalization of blood volume if reduced, followed by surgical resection of the tumor. Control of blood pressure extremes might be necessary during surgery, probably with nitroprusside.
Neal L. Benowitz, MD
A 35-year-old man presents with a blood pressure of 150/95 mm Hg. He has been generally healthy, is sedentary, drinks several cocktails per day, and does not smoke cigarettes. He has a family history of hypertension, and his father died of a myocardial infarction at age 55. Physical examination is remarkable only for moderate obesity. Total cholesterol is 220, and high-density lipoprotein (HDL) cholesterol level is 40 mg/dL. Fasting glucose is 105 mg/dL. Chest X-ray is normal. Electrocardiogram shows left ven-tricular enlargement. How would you treat this patient?