A 42-year-old man from Delhi presents to the emergency department with severe headache, profuse sweating, and palpitations for the past 2 hours. His wife reports he has had episodic hypertension for 6 months, with blood pressure readings ranging from 140/90 to 200/120 mmHg between episodes. On examination, BP is 185/110 mmHg, HR 118/min, and he appears anxious. Plasma metanephrines are markedly elevated at 4.2 nmol/L (normal <0.9). CT abdomen shows a 3.5 cm left adrenal mass. Which is the most appropriate next step in management before surgical intervention?

Explanation

## Diagnosis and Preoperative Preparation in Pheochromocytoma ### Clinical Presentation This patient has the classic triad of pheochromocytoma: - Episodic severe headache - Profuse diaphoresis - Palpitations with paroxysmal hypertension The elevated plasma metanephrines and imaging-confirmed adrenal mass confirm the diagnosis. ### Preoperative Pharmacological Preparation **Key Point:** Alpha-blockade MUST precede beta-blockade in pheochromocytoma management. This sequence prevents unopposed alpha-adrenergic stimulation and hypertensive crisis. **High-Yield:** The correct sequence is: 1. **Alpha-blockade first** (phenoxybenzamine or doxazosin) — titrate over 7–10 days until BP controlled and symptoms resolve 2. **Beta-blockade second** (propranolol or atenolol) — added only AFTER adequate alpha-blockade to control reflex tachycardia ### Why This Order Matters | Step | Agent | Purpose | Timing | |------|-------|---------|--------| | 1st | Phenoxybenzamine (non-selective, irreversible α-blocker) | Vasodilation, BP control, volume expansion | 7–10 days | | 2nd | Beta-blocker (propranolol preferred) | Control reflex tachycardia; only after α-blockade | Days 3–5 of α-blocker | **Clinical Pearl:** If beta-blockade is given before adequate alpha-blockade, unopposed alpha-adrenergic effects cause severe hypertension and coronary vasoconstriction — a potentially fatal complication. ### Mechanism Catecholamine excess causes: - Alpha-mediated vasoconstriction → hypertension - Beta-mediated tachycardia (reflex) Blocking alpha first relieves vasoconstriction and allows intravascular volume expansion. Beta-blockade is then safe and controls tachycardia. **Mnemonic:** **A-before-B** — Alpha before Beta in pheochromocytoma. ### Additional Preoperative Measures - Adequate hydration (IV fluids) to restore intravascular volume - Dietary salt loading - Avoid foods high in tyramine (cheese, cured meats) - Avoid NSAIDs and decongestants [cite:Harrison 21e Ch 397]