Pheochromocytoma-induced aggression?

Objective: To document a case of pheochromocytoma with an unusually high plasma ratio of norepinephrine to epinephrine concentrations (NE:E), and a history of violent and aggressive behavior (which has been reported to be associated with increased NE:E ratios).

Methods: We present the history of present illness, history of aggressive behavior, and the clinical course of a man who was found to have pheochromocytoma with a remarkable catecholamine profile. We also review the literature on the relationship of catecholamine ratios to behavior.

Results: A 33-year-old man presented to the emergency department with the chief complaint of palpitations and chest pain. A physical exam revealed markedly elevated blood pressure. On admission, a computed tomographic scan of the abdomen revealed a 10 by 10-cm heterogeneous mass of 20 Hounsfield units superior to the right kidney. His plasma NE:E ratio was 35, and his 24-hour urine ratio of normetanephrine to metanephrine concentrations was greater than 26. The tumor was successfully removed with laparoscopic adrenalectomy, and the histologic findings revealed benign pheochromocytoma. There was no immediate change in the patient's behavior. He was incarcerated the week after surgery, and lost to follow-up.

Conclusion: Primarily norepinephrine-producing pheochromocytoma may have contributed to this patient's violent and aggressive behavior. Catecholamine levels may remain elevated for 1 week following surgery. Even if this patient's norepinephrine level had dropped rapidly after removal of the pheochromocytoma, and was not elevated a week later when he was arrested, it is possible that his aggressive behavior may have been conditioned by long exposure to elevated levels of norepinephrine.