A 73-year-old woman with no remarkable medical history was admitted to our institution because of a 4-week course of recurrent episodes of dizziness, uncontrolled hypertension, and weight loss. Crises were stereotypical, beginning with headache, hot flush, profuse sweating, and quadriparesthesia followed by an increase in blood pressure and spontaneous resolution after 5 to 10 minutes. The results of a clinical examination after the episodes had subsided were normal. Suspicion of pheochromocytoma was supported by a large increase in norepinephrine levels in both serum and urine samples (serum norepinephrine, 14479 nmol/L [normal range, 1182-1773 nmol/L]; urinary norepinephrine, 1217.5 µmol per gram of creatinine [normal range, <532 µmol per gram of creatinine] [for 1 day]; urinary normetanephrine, 15937 µmol per gram of creatinine [normal range, <4200 µmol per gram of creatinine] [for 1 day]). There was no significant increase in either serum epinephrine or serotonin levels or urinary metanephrine and 5-hydroxyindoleacetic acid levels. Plasma levels of calcium, vasoactive intestinal polypeptide, gastrin, and calcitonin were also normal. Chest radiography showed a nodule (3-cm diameter) in the upper portion of the right lobe. A body computed tomographic scan and cerebral and medullar magnetic resonance imaging found no other localization of the tumor. Surprisingly, metaiodobenzylguanidine scintigraphy found no fixation, even in the lung. Before undergoing a surgical resection of her tumor, the patient died in a clinical episode of acute bowel occlusion. The autopsy revealed a lung bronchiolo-alveolar carcinoma with carcinomatous meningitis but no cerebral involvement. The tumor had no neuroendocrine differentiated cells since it was negative for neuron-specific enolase and chromogranin. Moreover, a meticulous examination of all the organs found no evidence of a neuroendocrine tumor, in keeping with the metaiodobenzylguanidine scintigraphy results. The cause of death could not be determined.
Thank you for submitting a comment on this article. It will be reviewed by JAMA Internal Medicine editors. You will be notified when your comment has been published. Comments should not exceed 500 words of text and 10 references.
Do not submit personal medical questions or information that could identify a specific patient, questions about a particular case, or general inquiries to an author. Only content that has not been published, posted, or submitted elsewhere should be submitted. By submitting this Comment, you and any coauthors transfer copyright to the journal if your Comment is posted.
* = Required Field
Disclosure of Any Conflicts of Interest*
Indicate all relevant conflicts of interest of each author below, including all relevant financial interests, activities, and relationships within the past 3 years including, but not limited to, employment, affiliation, grants or funding, consultancies, honoraria or payment, speakers’ bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. If all authors have none, check "No potential conflicts or relevant financial interests" in the box below. Please also indicate any funding received in support of this work. The information will be posted with your response.
Some tools below are only available to our subscribers or users with an online account.
Download citation file:
Web of Science® Times Cited: 3
Customize your page view by dragging & repositioning the boxes below.
More Listings atJAMACareerCenter.com >
The Rational Clinical Examination
Make the Diagnosis: Cancer, Family History
The Rational Clinical Examination
Original Article: Does This Patient Have a Family History of Cancer?
All results at
Enter your username and email address. We'll send you a link to reset your password.
Enter your username and email address. We'll send instructions on how to reset your password to the email address we have on record.
Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.