What are the key symptoms and diagnostic steps for phaeochromocytoma. How is 123I-MIBG SPECT scan used in diagnosis. What is the significance of thyroid nodules in this condition. How should a patient with suspected phaeochromocytoma be managed.

Unraveling the Mystery: A 39-Year-Old Woman’s Perplexing Symptoms

In the realm of medical diagnostics, some cases present a intricate web of symptoms that challenge even the most experienced healthcare professionals. Such is the case of a 39-year-old woman who sought medical attention for a decade-long history of episodic headaches, sweating, and palpitations. These symptoms had intensified over the past one to two years, evolving into a more complex clinical picture.

The patient reported experiencing three to four episodes daily, predominantly at night, characterized by:

• Severe headaches
• Chest tightness
• Profuse sweating
• Palpitations
• A sensation described as a “churning stomach”

Intriguingly, the patient had no significant medical history and was not taking any regular medications. However, her family history revealed that her mother had been diagnosed with metastatic cancer of unknown origin in her early 60s, adding another layer of complexity to the diagnostic puzzle.

Clinical Examination and Initial Findings: Piecing Together the Clues

Upon physical examination, the following observations were made:

• Blood pressure: 100/80 mm Hg (with no postural drop)
• Pulse: 86 beats/min (regular)
• A palpable left thyroid nodule (without associated lymphadenopathy)
• Otherwise unremarkable systemic examinations

The presence of a thyroid nodule in conjunction with the reported symptoms raised suspicions and prompted further investigation. Initial diagnostic steps included:

1. Magnetic resonance imaging (MRI) of the head, which showed no abnormalities
2. Thyroid function tests, which returned normal results
3. 24-hour urinary catecholamine tests, performed twice, revealing markedly elevated levels:
   • Noradrenaline: 628 nmol/L and 613 nmol/L (reference range: 0-450)
   • Adrenaline: 722 nmol/L and 915 nmol/L (reference range: 0-100)

These elevated catecholamine levels strongly suggested the possibility of phaeochromocytoma, a rare neuroendocrine tumor that originates in the adrenal glands.

Advanced Imaging Techniques: Shedding Light on the Diagnosis

To further investigate the suspected phaeochromocytoma, additional imaging studies were conducted:

1. MRI of the adrenal glands revealed:
   • A large mass in the right upper quadrant
   • A small mass in the left adrenal gland
2. An iodine-123-meta-iodobenzylguanidine (123I-MIGB) single photon emission computed tomography (SPECT) scan was performed

The 123I-MIBG SPECT scan is a highly specific imaging technique used in the diagnosis of neuroendocrine tumors, particularly phaeochromocytomas. In this case, the scan revealed increased uptake of the radioactive marker in three distinct areas:

• The right upper abdomen
• The region of the left adrenal gland
• The left thyroid lobe

These findings provided crucial information for the diagnosis and subsequent management of the patient’s condition.

The Significance of Thyroid Nodules in Phaeochromocytoma Cases

The presence of a thyroid nodule in this patient raises important considerations. While thyroid nodules are relatively common in the general population, their occurrence in patients with suspected phaeochromocytoma warrants special attention. In this context, the thyroid nodule could potentially indicate:

1. A coincidental finding unrelated to the primary condition
2. A manifestation of multiple endocrine neoplasia (MEN) syndrome, particularly MEN 2A or MEN 2B
3. Metastatic spread from the primary phaeochromocytoma
4. A separate primary thyroid neoplasm

Given the increased uptake of 123I-MIBG in the left thyroid lobe, as shown by the SPECT scan, the possibility of metastatic spread or a separate neuroendocrine tumor in the thyroid gland becomes a significant consideration.

Further Investigations: Delving Deeper into the Diagnosis

To gain a comprehensive understanding of the patient’s condition and to guide appropriate treatment, several additional investigations should be considered:

1. Fine-needle aspiration (FNA) biopsy of the thyroid nodule to determine its nature
2. Genetic testing for mutations associated with hereditary phaeochromocytoma syndromes, such as:
   • RET proto-oncogene (associated with MEN 2)
   • VHL gene (von Hippel-Lindau syndrome)
   • SDHx genes (hereditary paraganglioma-pheochromocytoma syndrome)
3. Plasma metanephrine and normetanephrine levels to complement the urinary catecholamine findings
4. Comprehensive hormonal workup to exclude other endocrine abnormalities
5. Contrast-enhanced CT or MRI of the chest, abdomen, and pelvis to evaluate for potential metastatic disease

These investigations will provide a more complete picture of the extent of the disease and help guide treatment decisions.

Management Strategies: A Multidisciplinary Approach

The management of this patient requires a carefully coordinated multidisciplinary approach, involving endocrinologists, surgeons, radiologists, and potentially oncologists. The primary steps in management include:

1. Preoperative medical management:
   • Alpha-adrenergic blockade (e.g., phenoxybenzamine or doxazosin) to control blood pressure and prevent hypertensive crises
   • Beta-blockers may be added after adequate alpha-blockade to control tachycardia
   • Adequate hydration and salt intake to prevent postoperative hypotension
2. Surgical intervention:
   • Laparoscopic or open adrenalectomy for the right adrenal mass
   • Potential left adrenalectomy, depending on the nature of the smaller left adrenal mass
   • Consideration of thyroidectomy if the thyroid nodule is confirmed to be malignant or part of a MEN syndrome
3. Postoperative care and monitoring:
   • Close monitoring of blood pressure and catecholamine levels
   • Hormone replacement therapy if bilateral adrenalectomy is performed
   • Long-term follow-up to detect recurrence or metastatic disease
4. Genetic counseling and family screening if hereditary syndromes are identified

The complexity of this case highlights the importance of a thorough diagnostic workup and a tailored management plan for patients presenting with symptoms suggestive of phaeochromocytoma.

Long-Term Prognosis and Follow-Up: Navigating the Road Ahead

The long-term prognosis for patients with phaeochromocytoma varies depending on several factors, including the size and location of the tumor(s), the presence of metastatic disease, and any associated genetic syndromes. In this patient’s case, the presence of bilateral adrenal masses and potential thyroid involvement complicates the picture.

Key aspects of long-term follow-up include:

• Regular biochemical screening (plasma or urinary metanephrines) to detect recurrence
• Periodic imaging studies (CT, MRI, or MIBG scans) to assess for local recurrence or metastatic disease
• Ongoing surveillance for the development of other endocrine tumors, particularly if a genetic predisposition is identified
• Lifelong endocrine replacement therapy in cases of bilateral adrenalectomy
• Psychosocial support and counseling to address the impact of the diagnosis and treatment on the patient’s quality of life

With appropriate management and vigilant follow-up, many patients with phaeochromocytoma can achieve good long-term outcomes. However, the potential for recurrence or the development of metastatic disease necessitates ongoing medical attention and patient education.

Advancing Research and Treatment Options: Looking to the Future

The field of phaeochromocytoma research is rapidly evolving, with ongoing studies aimed at improving diagnosis, treatment, and long-term outcomes for patients. Some promising areas of research include:

• Development of more sensitive and specific biomarkers for early detection and monitoring of disease progression
• Advancements in imaging techniques to enhance localization and characterization of tumors
• Exploration of targeted therapies based on genetic and molecular profiling of tumors
• Investigation of minimally invasive surgical techniques to reduce postoperative complications and recovery time
• Evaluation of novel radionuclide therapies for metastatic or inoperable disease

As our understanding of the genetic and molecular basis of phaeochromocytoma continues to grow, there is hope for more personalized and effective treatment strategies in the future. This case serves as a reminder of the importance of thorough clinical investigation and the potential for complex presentations in endocrine disorders.

The journey from initial presentation to diagnosis and management of phaeochromocytoma is often challenging, requiring a high index of suspicion, careful clinical assessment, and a multidisciplinary approach. By sharing and analyzing cases such as this, healthcare professionals can continue to refine their diagnostic skills and improve patient outcomes in this rare but potentially life-threatening condition.

A woman with episodic headaches, sweating, and palpitations

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BMJ
2011;
342
doi: https://doi. org/10.1136/bmj.d2977
(Published 29 June 2011)

Cite this as: BMJ 2011;342:d2977

• Article
• Related content
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• Peer review

1. Angus Jones, specialist registrar1,
2. Matthew Bull, specialist registrar2,
3. Bijay Vaidya, consultant endocrinologist and honorary reader1

1. ¹Department of Endocrinology, Royal Devon and Exeter Hospital, Exeter EX2 5DW, UK
2. ²Department of Radiology, Royal Devon and Exeter Hospital

1. Correspondence to: B Vaidya bijay.vaidya{at}pms.ac.uk

A 39 year old woman was referred to the headache clinic with a 10 year history of episodic headaches, sweating, and palpitations. The symptoms had intensified over the past one to two years. Since then she has been experiencing three to four episodes a day, mostly at night, of severe headache, chest tightness, sweating, palpitations, and “churning stomach. ” She had no medical history of note and took no regular drugs. Her mother had been diagnosed with metastatic cancer of unknown source in her early 60s.

On examination, her blood pressure was 100/80 mm Hg, with no postural drop; pulse was 86 beats/min and regular. She had a palpable left thyroid nodule but no associated lymphadenopathy, and other systemic examinations were unremarkable.

Magnetic resonance imaging of the head showed no abnormalities. Thyroid function tests were normal; 24 hour urinary catecholamines performed twice showed markedly raised noradrenaline (628 nmol/L and 613 nmol/L; reference range 0-450) and adrenaline (722 nmol/L and 915 nmol/L; 0-100), suggestive of phaeochromocytoma. Magnetic resonance imaging of the adrenals showed a large mass in the right upper quadrant and a small mass in the left adrenal. An iodine-123-meta-iodobenzylguanidine (¹²³I-MIGB) single photon emission computed tomography (SPECT) scan (fig 1⇓) was performed.

Fig 1 Coronal ¹²³I-MIBG SPECT fusion scan

Questions

• 1 What does the ¹²³I-MIBG SPECT scan show?

• 2 What is the possible importance of the thyroid nodule?

• 3 What further investigations would you perform?

• 4 How would you manage this patient?

Answers

1 What does the

¹²³I-MIBG SPECT scan show?

Short answer

The ¹²³I-MIBG SPECT scan shows increased uptake of marker in the right upper abdomen, and in the regions of the left adrenal gland and left thyroid lobe.

Long answer

MIBG is a precursor of catecholamines. Radiolabelled ¹²³I-MIBG or ¹³¹I-MIBG enters the catecholamine synthesis pathway and concentrates within phaeochromocytomas and other neuroendocrine tumours.1 In suspected …

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Hyperhidrosis And Migraine Headache Treatments

TREATMENT OF HYPERHIDROSIS AND MIGRAINES HEADACHES WITH BOTOX

Botox has far more uses than simply removing the wrinkles on the upper third of the face. In fact, Botox first received FDA approval not for wrinkle treatment, but for treatment of involuntary eyelid spasms. At New Image Medical Spa, in addition to wrinkles, we use Botox to treat excessive sweating and migraine headaches.

HYPERHIDROSIS — EXCESSIVE SWEATING

The human body uses perspiration to cool the skin when the temperatures are warm or when the person is exercising/using his or her body physically. Hyperhidrosis is a condition where the body sweats excessively and the sweating is not related to temperature or activity. Hyperhidrosis can cause the person to sweat so much that is soaks through the clothes and can drip off the hands. Obviously, this disrupts normal activities, but it is also a source of social anxiety and embarrassment.

WHAT CAUSES EXCESSIVE SWEATING?

When we sweat normally, the nervous system triggers the sweat glands to activate in response to a rise in body temperature. When a person has hyperhidrosis, the nerves that trigger perspiration become overactive and trigger a sweat response without a rise in body temperature.

In primary hyperhidrosis, there isn’t any other contributor, such as another health condition. Primary hyperhidrosis usually affects the palms, soles of the feet, and sometimes the face. There seems to be a genetic/hereditary component to this type of hyperhidrosis.

In secondary hyperhidrosis, the excessive sweating is due to an underlying medical condition. With secondary hyperhidrosis, the sweating is likely to come all across the body. These are health factors that can be part of this type of hyperhidrosis:

• Diabetes
• Menopause
• Low blood sugar
• Certain medications
• Overactive thyroid gland
• Nervous system disorders
• Some types of cancer
• Heart attack

TREATING EXCESSIVE SWEATING

Different treatments can be used to attempt to stop hyperhidrosis — from using low-level electrical current across the hands and feet to prescription-strength antiperspirants to surgical removal of the sweat glands. One of the most successful treatments, however, has proven to be the injection of Botox.

Botox is called a neuromodulator. When injected in minute amounts, the botulinum toxin in Botox blocks the nerve messages sent to the brain. In the case of wrinkles, Botox blocks the messages to contract muscles that form wrinkles with making expressions such as squinting (crow’s feet wrinkles). With excessive sweating, Botox blocks the messages from the nerves to trigger the sweat glands. The FDA has approved Botox for use treating hyperhidrosis on the underarm area. It can also be used “off-label” on the palms and the soles of the feet.

HOW WE USE BOTOX FOR EXCESSIVE SWEATING

At New Image Medical Spa, we inject Botox in a series of several injections in the underarms. The needle used is very tiny, and there is little discomfort. The injections take from 4-5 days to fully stop the nerve messages that trigger sweat gland activation. Once this has occurred, sweating is reduced for 4 to 6 months, sometimes longer. When the body eventually absorbs the inert Botox, sweating will return. At that point, another Botox session at New Image will continue to decrease your sweating.

AFTER EXCESSIVE SWEATING TREATMENT

You may have some very minor soreness at a couple of the injection sites, but that is minimal. Otherwise, it will take 4-5 days to decrease your sweating. Then for up to the next half year, your sweating should be markedly decreased.

MIGRAINES

A migraine can cause severe, debilitating pain, requiring the person to often lie down in a darkened room until the migraine passes. Migraines cause severe throbbing pain or a pulsing sensation. They usually occur just on one side of the head, and they are often accompanied by nausea, vomiting, and extreme sensitivity to sound and light. A migraine can last for hours, even days. Chronic migraines are classified as a person having a migraine at least 15 days per month.

At New Image, we use Botox for treatment of chronic migraines.

WHAT CAUSES MIGRAINES?

The causes of migraine headaches are still somewhat of a scientific mystery. Both genetic and environmental factors are thought to be involved. Migraines may be related to an imbalance in brain chemicals, especially serotonin, which helps regulate pain in the nervous system. Migraines may also be caused by changes in the brainstem and the trigeminal nerve.

ARE THERE DIFFERENT TYPES OF MIGRAINES?

There are seven classified types of migraines. These are the two main types:

• Migraine without aura — Formerly known as a “common migraine,” this is the most frequent type of migraine. Symptoms include moderate to severe pulsating headache pain on one side of the head. With the pain also come nausea, blurred vision, confusion, mood changes, fatigue, and increased sensitivity to sound and light. This type of migraine worsens with frequent use of headaches medications.

• Migraine with aura — Formerly known as a “classic or complicated migraine,” this type of migraine includes visual disturbances and other neurological symptoms (abnormal sensation, numbness, muscle weakness on one side of the body, tingling in the hands or face, trouble speaking, confusion) that show themselves from 10 to 60 minutes before the actual headache begins. Nausea, loss of appetite, and increased sensitivity to light and sound may also precede the headache.

HOW DOES BOTOX HELP WITH MIGRAINES?

In 2010, the FDA approved the use of Botox for treatment of “chronic migraines.” These are migraines that occur on at least 15 days each month. Botox appears to work better in cases of more frequent migraines. The FDA did not approve Botox for use on non-chronic migraines.

Botox is made of the botulinum toxin, a neurotoxin produced by the bacteria that cause botulism. In the 50s it was discovered that when this neurotoxin is injected into a muscle in a very tiny amount, it temporarily paralyzes the muscle. Botox is well known for its cosmetic treatment of wrinkles. When erasing wrinkles, the injected Botox stops muscles that form wrinkles on the upper third of the face. Botox blocks the nerve message from getting to the brain, so the muscle is not ordered to contract. Without the contraction, the wrinkle above the muscle doesn’t form.

For migraines, Botox is injected around the pain fibers involved in headaches. The Botox enters the nerve endings in the injection area and blocks the release of chemicals involved in pain transmission. Without these chemicals, pain networks in the brain are not activated.

Botox prevents migraines; it doesn’t address them once they start. It takes time to work. Usually the second or third treatment session shows the maximum effect. One treatment session lasts from 10-12 weeks.

HOW IS BOTOX INJECTED FOR MIGRAINES?

At New Image Medical Spa, we use a very tiny needle for our Botox injections. The injections will feel like a pinprick. We inject the Botox into shallow muscles in the skin, using 31 injections in seven key areas of the head and neck.

After your session, you may have some neck soreness, but this is temporary and an ice pack will reduce any discomfort.

WILL INSURANCE COVER MY BOTOX MIGRAINE TREATMENT?

If you have chronic migraines (at least 15 days per month), insurance will usually cover treatment. However, in most cases you must have tried and failed to respond to two other preventative measures first. These are treatments such as the use of blood pressure or anti-seizure medications.

Contact Us Today!

Call the office to schedule your consultation at 510-790-8821 or click here to fill out your online request.

Migraine, symptoms, causes, prevention, and treatment – clinic AMC Barnaul

07.09.2018

One of the varieties of cephalalgia is a neurological disease such as migraine, or hemicrania. This disease is quite common, it affects every seventh person on the planet, mostly 20-30-year-old women. This disease interferes with a normal life and enjoyment of life and leads to depression,
anxiety, malfunctions of the normal functioning of other organs and systems of the body.

Main symptoms

Migraine is a paroxysmal, unilateral, throbbing headache that manifests itself with varying frequency: both several times a year and several times a month. Nausea and vomiting, which are not able to bring relief, are also considered important symptoms.

In addition, the following may be observed:

• impaired vision and speech;

• numbness, tingling and weakness in the limbs;

• dizziness;

• painful reaction to light and noise;

• increased sweating;

• pain in the abdomen;

• feeling irritable, depressed, tired.

Each of these symptoms may, although not always, be a harbinger of the onset of a migraine, this condition is called a “prodrome”, and a set of specific sensations that precede an attack and accompany it is called an “aura”. The presence or absence of such conditions is purely individual.

Reasons for the appearance of

Often migraine begins to manifest itself in adolescence at
puberty, but it can happen at any time in life. To date, the causes of this condition are not known for certain, except that it is associated with disorders in the structures of the brain.

Among the main factors provoking seizures are the following:

• heredity;

• hormonal disruptions;

• intense physical activity;

• overwork;

• frequent stress and anxiety;

• sleep deprivation or excess sleep;

• weather change;

• change of climate zone;

• alcohol and smoking;

• malnutrition;

• menstruation;

• low blood sugar;

• insufficient water intake (dehydration).

Methods of treatment and prevention

As with any other disease, it is important to consult a doctor in time for timely and effective therapy. The most effective in the treatment of this disease will be well-chosen drugs for stopping an attack (for example, ibuprofen, paracetamol, analgin). In addition, you can additionally use antiemetics. In more severe and advanced cases, the doctor may prescribe specific anti-migraine agents that affect pathological processes (for example, ergotamine-containing drugs or triptans).

There is also prevention, which is indicated in cases where the rest are ineffective. It should be noted that the lack of treatment can lead to the development of complications from the cardiovascular system and parts of the brain, which in turn can provoke a stroke or heart attack. Unfortunately, it is impossible to completely recover from this disease. Therefore, it is absolutely necessary to lead a healthy lifestyle, exercise regularly and eat right in order to avoid attacks of hemicrania.

Migraine treatment in Barnaul

Patients suffering from hemicrania should seek advice from experienced and qualified specialists, primarily a neurologist, who will take an anamnesis, conduct an examination and prescribe a therapy that suits you. If necessary, the doctor can send you for an additional laboratory diagnostic examination. In addition to drug therapy, you may be prescribed physiotherapeutic procedures, such as massage, acupuncture, hirudotherapy, electrophoresis, etc. You should not endure a headache
pain and self-medicate, because all this can only aggravate an already difficult condition.

It is possible to get consulting services, as well as effective treatment of migraine in Barnaul, at the Altai Medical Center,
where professionals work. You can make an appointment with a neurologist both by phone and on the website of the medical center.

Increased sweating. Causes of excessive sweating

Have you noticed that you began to sweat much more than before? Perhaps the heat is not the only reason why you are worried about excessive sweating.

Excessive sweating is medically called hyperhidrosis. There can be many reasons, starting with the lability of the nervous system, in which the sweat glands are always “on edge”, and ending with the peculiarities of anatomy and behavior. For example, too superficial arrangement of sweat glands, more than usual, their number or the habit of drinking a lot of water.

But in this case, the person has been sweating a lot since childhood, at most since puberty, and has known his problem for a long time. We are interested in the situation when a person did not sweat much before, and then suddenly it started.

Idiopathic hyperhidrosis

The word “idiopathic” means “without a clearly established cause”.

That is, a person sweats, but there seems to be no reason. In fact, it exists, and not just one, but a whole complex. A classic of the genre is a young woman with an unstable nervous system. When hormonal storms of puberty or fluctuations associated with the monthly cycle, pregnancy, feeding, restoration of the cycle and pregnancy again are superimposed on the existing vegetovascular dystonia, try not to sweat here.

Fortunately, most often after 35 years of age, the hormonal status stabilizes and hyperhidrosis disappears.

What to do?

Consult a dermatologist for the correct selection of skin care and antiperspirant products.

Diabetes mellitus

Diabetes mellitus is almost always accompanied by increased sweating. The reason is a metabolic disorder and damage to small nerves as a result of diabetic polyneuropathy. As a result, the connection of blood vessels and sweat glands with the brain deteriorates, and thermoregulation disorders occur. In addition, constant thirst, frequent urination, dry mouth are of concern.

What to do?

Take a blood test for fasting glucose and glycated hemoglobin – an indicator of the average blood sugar level over the past 3 months.

Hyperthyroidism

It is caused by hyperthyroidism. Imagine a picture: coal is constantly thrown into the furnace of a steam locomotive, and it throws out clouds of black smoke and rushes along the rails at full steam. So hyperthyroidism spins the flywheel of metabolism, forcing the body to develop its resource to the limit. A person eats all the time, but loses weight, he is constantly hot, sweat flows in streams even in a cool room. The highest degree of hyperthyroidism is thyrotoxicosis: in fact, poisoning with an excess of hormones and metabolic products that the body does not have time to utilize. Hospitalization required. So if others notice that you have become too active and talkative, constantly turn on the air conditioner or open the window when everyone else is freezing, it may be time to go to the doctor.

What to do?

Visit an endocrinologist, donate blood for thyroid hormones – TSH, T3, T4.

Tuberculosis

The statistics are inexorable: tuberculosis has ceased to be a disease of the slums, and more than half of TB patients are young, socially successful people. Even in the medical school they teach that tuberculosis is a real monkey, the mask of all diseases. And often the only manifestations of this disease are subfebrile temperature in the evenings (up to 37. 2-37.5 ° C, not higher) and constant sweating, especially at night.

If this continues for more than two weeks, and it is not SARS, see a physician.

What to do?

If your GP suspects TB, he or she will refer you to a TB specialist who will order a comprehensive examination.

Lymphogranulomatosis and other blood diseases

Excessive sweating at night may be the only sign of dangerous malignant blood diseases – lymphogranulomatosis (Hodgkin’s disease), lymphoma and even leukemia. Recall that most of these diseases, despite their malignant nature, are currently successfully treated. For example, lymphogranulomatosis is completely cured in 90% of cases.

And the sooner the diagnosis is made, the higher the chances of recovery. In addition to sweating, skin itching, unmotivated weight loss, low-grade fever may disturb. If you have these symptoms, examine the lymph nodes yourself – on the back of the head, neck, supraclavicular areas, armpits and buttermilk.