Research Article

Pheochromocytoma Unmasked: An Unexpected  Discovery During Pre-Anesthetic Evaluation in a  Child with Femoral Shaft Fracture 

Kartik Sonawane.1 Palanichamy Gurumoorthi.2

• .1Consultant Anesthesiologist, Dept. of Anesthesiology, Ganga Medical Centre & Hospitals, Pvt. Ltd., Coimbatore, Tamil Nadu, India 
• .2Senior Consultant Anesthesiologist, Dept. of Anesthesiology, Ganga Medical Centre & Hospitals, Pvt. Ltd., Coimbatore, Tamil Nadu, India
•  

Correspondence: Kartik Sonawane, EDRA, Consultant Anesthesiologist, Department of Anesthesiology, Ganga Medical Centre & Hospitals, Pvt. Ltd. Coimbatore, Tamil Nadu, India, Email: [email protected]

Received: January 15, 2026                                                          Published: January 27, 2026

Citation: Kartik S. Pheochromocytoma Unmasked: An Unexpected Discovery During Pre-Anesthetic Evaluation in a Child with Femoral Shaft Fracture. AOJ Ortho and Rheum. 2026;1(1):01–09. 

Copyright: ©2026 Kartik S. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and build upon your work non commercially.

Abstract 

Pheochromocytoma is a rare catecholamine-secreting tumor that may mimic perioperative pain- or anxiety-related sympathetic activation, placing undiagnosed patients at risk of catastrophic hemodynamic events during anesthesia. A 12-year-old boy scheduled for titanium elastic nailing of a femoral shaft fracture was noted to have persistent tachycardia and hypertension in the preoperative holding area. Despite sedation with midazolam, analgesia with fentanyl, and an effective femoral nerve block, his heart rate and blood pressure remained elevated. Focused caregiver history revealed several months of excessive sweating, heat intolerance, and refusal to wear clothes, prompting urgent endocrinology consultation, cancellation of surgery, and further evaluation. Ultrasonography and contrast-enhanced CT demonstrated bilateral adrenal masses (left 8 × 6 cm; right 2.7 × 2.5 cm), and 24-hour urinary normetanephrine was markedly elevated (15,422.6 µg/day), confirming bilateral pheochromocytoma. After preoperative alpha- followed by beta-blockade, the child underwent laparoscopic bilateral adrenalectomy under invasive hemodynamic monitoring. Histopathology confirmed pheochromocytoma with intermediate-risk features. He later underwent femoral fixation uneventfully under neuraxial anesthesia. This case underscores that persistent sympathetic activation unexplained by pain or anxiety warrants evaluation for secondary causes and highlights the diagnostic value of pre-anesthetic vigilance and caregiver observations in pediatric patients. 

Keywords: Pheochromocytoma; Pre-anesthetic evaluation; Pediatric hypertension; Catecholamine crisis; Femoral fracture; Clinical vigilance; Bilateral adrenal tumor; Perioperative diagnosis; Heat intolerance; Caregiver history

References

1. Lenders JW, Duh QY, Eisenhofer G, et al. Pheochromocytoma and paraganglioma: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2014;99(6):1915-1942. 
2. Armstrong R, Sridhar M, Greenhalgh KL, et al. Phaeochromocytoma in children. Arch Dis Child. 2008;93(10):899-904. 
3. Beltsevich DG, Kuznetsov NS, Kazaryan AM, Lysenko MA. Pheochromocytoma surgery: epidemiologic peculiarities in children. World J Surg. 2004;28(6):592-596. 
4. Waguespack SG, Rich T, Grubbs E, et al. A current review of the etiology, diagnosis, and treatment of pediatric pheochromocytoma and paraganglioma. J Clin Endocrinol Metab. 2010;95(5):2023-2037. 
5. Ramakrishna H. Pheochromocytoma resection: Current concepts in anesthetic management. J Anaesthesiol Clin Pharmacol. 2015;31(3):317-323. 
6. Pham TH, Moir C, Thompson GB, et al. Pheochromocytoma and paraganglioma in children: a review of medical and surgical management at a tertiary care center. Pediatrics. 2006;118(3):1109-1117. 
7. Stein PP, Black HR. A simplified diagnostic approach to pheochromocytoma. A review of the literature and report of one institution’s experience. Medicine (Baltimore). 1991;70(1):46-66. 
8. Naranjo J, Dodd S, Martin YN. Perioperative Management of Pheochromocytoma. J Cardiothorac Vasc Anesth. 2017;31(4):1427-1439. 
9. Prys-Roberts C. Phaeochromocytoma--recent progress in its management. Br J Anaesth. 2000;85(1):44-57. 
10. Kinney MA, Narr BJ, Warner MA. Perioperative management of pheochromocytoma. J Cardiothorac Vasc Anesth. 2002;16(3):359-369. 
11. Tischler AS. Pheochromocytoma and extra-adrenal paraganglioma: updates. Arch Pathol Lab Med. 2008;132(8):1272-1284. 
12. Ciftci AO, Tanyel FC, Senocak ME, Büyükpamukçu N. Pheochromocytoma in children. J Pediatr Surg. 2001;36(3):447-452. 
13. Bausch B, Schiavi F, Ni Y, et al. Clinical Characterization of the Pheochromocytoma and Paraganglioma Susceptibility Genes SDHA, TMEM127, MAX, and SDHAF2 for Gene-Informed Prevention. JAMA Oncol. 2017;3(9):1204-1212. 
14. Eisenhofer G, Goldstein DS, Walther MM, et al. Biochemical diagnosis of pheochromocytoma: how to distinguish true- from false-positive test results. J Clin Endocrinol Metab. 2003;88(6):2656-2666. 
15. Eisenhofer G, Rivers G, Rosas AL, Quezado Z, Manger WM, Pacak K. Adverse drug reactions in patients with phaeochromocytoma: incidence, prevention and management. Drug Saf. 2007;30(11):1031-1062. 
16. Havekes B, Romijn JA, Eisenhofer G, Adams K, Pacak K. Update on pediatric pheochromocytoma. Pediatr Nephrol. 2009;24(5):943-950. 
17. O'Riordan JA. Pheochromocytomas and anesthesia. Int Anesthesiol Clin. 1997;35(4):99-127.
18. Lenders JW, Duh QY, Eisenhofer G, et al. Pheochromocytoma and paraganglioma: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2014;99(6):1915-1942. 
19. Bausch B, Borozdin W, Neumann HP; European-American Pheochromocytoma Study Group. Clinical and genetic characteristics of patients with neurofibromatosis type 1 and pheochromocytoma. N Engl J Med. 2006;354(25):2729-2731. 
20. Pacak K. Preoperative management of the pheochromocytoma patient. J Clin Endocrinol Metab. 2007;92(11):4069-4079. 
21. Buitenwerf E, Osinga TE, Timmers HJLM, et al. Efficacy of α-Blockers on Hemodynamic Control during Pheochromocytoma Resection: A Randomized Controlled Trial. J Clin Endocrinol Metab. 2020;105(7):2381-2391. 
22. Agrawal R, Mishra SK, Bhatia E, et al. Prospective study to compare perioperative hemodynamic alterations following preparation for pheochromocytoma surgery by phenoxybenzamine or prazosin. World J Surg. 2014;38(3):716-723. 
23. Prys-Roberts C, Farndon JR. Efficacy and safety of doxazosin for perioperative management of patients with pheochromocytoma. World J Surg. 2002;26(8):1037-1042.
24. Naranjo J, Dodd S, Martin YN. Perioperative Management of Pheochromocytoma. J Cardiothorac Vasc Anesth. 2017;31(4):1427-1439. 
25. Scholten A, Cisco RM, Vriens MR, et al. Pheochromocytoma crisis is not a surgical emergency. J Clin Endocrinol Metab. 2013;98(2):581-591. 
26. Ramakrishna H. Pheochromocytoma resection: Current concepts in anesthetic management. J Anaesthesiol Clin Pharmacol. 2015;31(3):317-323. 
27. Bornstein SR, Allolio B, Arlt W, et al. Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2016;101(2):364-389. 
28. Thompson LD. Pheochromocytoma of the Adrenal gland Scaled Score (PASS) to separate benign from malignant neoplasms: a clinicopathologic and immunophenotypic study of 100 cases. Am J Surg Pathol. 2002;26(5):551-566. 

Fishbein L, Leshchiner I, Walter V, et al. Comprehensive Molecular Characterization of Pheochromocytoma and Paraganglioma. Cancer Cell. 2017;31(2):181-193.