1511 - From TBI to Tumor: Presumed persistent post-traumatic sequelae found to be a malignant pheochromocytoma

Case Diagnosis: Malignant Pheochromocytoma

Case Description: We detail the novel case of a 59-year-old female receiving long-term physiatric management of residual cognitive impairments, neuropathic pain, and mood disturbance secondary to her traumatic brain injury (TBI). She reported persistent anxiety and mood lability, initially treated as sequelae of her TBI. She further developed heart palpitations, hyperhidrosis, and worsening tachycardia. Despite efforts to modify her medical treatment and minimize medication side effects, her symptoms worsened. A thorough review of her medical records revealed mention of a left adrenal nodule 8 years prior with no reported follow-up. Following this discovery, CT imaging was ordered. Imaging demonstrated progressive enlargement from 1 cm to a 4.5 cm adrenal mass, prompting a referral to Endocrinology. Further workup revealed a malignant pheochromocytoma. The patient underwent surgical resection with significant improvement in her autonomic symptoms and mood dysregulation, leading to the weaning and discontinuation of previously prescribed medications.

Discussions: 40-60% of people living with TBI experience chronic symptoms that can be attributed to post-injury sequelae. When new symptoms present, or uncharacteristically worsen, a logical next step for physiatrists is to evaluate the patient’s medications for potential side effects. However, when management is suboptimal or fails, it is important to broaden the differential diagnosis. There is limited scientific literature on non-neurologic conditions that mimic post-TBI sequelae. Despite the significant overlap in pheochromocytoma presentation, there are no reported cases of a pheochromocytoma presenting as chronic TBI symptoms.

Conclusions: This case highlights the importance of maintaining a high index of suspicion when caring for TBI patients. Although many symptoms can be attributed to post-TBI sequelae, unrelated conditions, like a pheochromocytoma, can be the cause, especially when a patient exhibits an unexpected treatment response or an unexplained symptom exacerbation. Conducting a systematic review exploring diagnoses with similar symptomatology to TBI sequelae would be valuable in providing future guidance.