Recurrent Hypertensive Crises in an Endoscopist: A Possible Occupational Link

Abstract

A middle-aged gastroenterologist with a history of wellcontrolled hypertension and impaired fasting glucose was repeatedly hospitalized for hypertensive crises. Several weeks prior to presentation, the patient began to experience episodes of searing "hot poker" occipital headache immediately followed by facial flushing and neck rash associated with blood pressures (BPs) >170/ 120 mm Hg while performing endoscopy, all of which resolved following completion of the procedure. Of note, the endoscopist was required to rotate and extend his neck to view video monitors while performing endoscopy. These episodes continued to intensify, and the patient required seven hospitalizations during a period of 3 weeks for stabilization and treatment of BP values exceeding 230/130 mm Hg.The patient's medical history was significant only for hypertension well controlled with a single agent and impaired fasting glucose not requiring medication. He did not have any toxic habits or psychosocial stressors. He did not have a history of neck trauma, surgery, or radiation. He did not have a family history of pheochromocytoma.Physical examination of the patient was significant for orthostatic hypertension and an erythematous rash on his neck. An increase in BP >30 mm Hg could be elicited with neck rotation, chewing, and talking. With an arterial line in place, the patient's BP was observed to instantly increase whenever he rotated his neck to the left, as he would when performing endoscopy. There was no carotid or abdominal bruit. Funduscopic examination found no evidence of chronic hypertensive changes.Comprehensive serologic testing included electrolytes, renal function, hepatic function, thyroid function, catecholamines, renin, aldosterone, serotonin, dopamine, chromogranin, and tryptase, which were within normal limits. Results from urine catecholamines, metanephrines, and 5-hydroxyindoleacetic acid were within normal limits. Comprehensive imaging including magnetic resonance imaging and magnetic resonance angiography of the brain, neck, and abdomen; cardiac catheterization; and whole-body positron emission tomographic, octreotide, and radiopharmaceutical metaiodobenzylguanidine scans failed to find an adrenal tumor or extra-adrenal paraganglioma or carotid glomus tumor. Nocturnal oxygen saturation did not fall below 90%. Tilt table autonomic testing, performed once while the patient was taking antihypertensive medications, was inconclusive.The patient's BP was ultimately stabilized on a regimen of amlodipine and labetalol. He does, however, continue to have occasional breakthrough episodes and can intentionally elicit them by rotating his neck to the left. Because of the disabling nature of his condition, the patient retired from his practice.