A 45 yo M present to ER c/o elevated BP. His BP at home was 180/100 mmHg for many weeks. He has had a chronic HA for many years, however a week ago he developed a different type of headache. It starts in the occipital area and goes in waves towards the vertex. It seems to be worse at night. He started loosing more hair, despite applying the same amount of testosterone gel daily. And here is the piece of information that reinforced to me this was the real deal: 'Doctor, I am gay'.
He was describing the classical headache for neurosyphilis. RPR was 1:128. Spinal tap showed 50 lymphs. His free testosterone was normal, so probably the alopecia was secondary to syphilis, although it was not the typical alopecia areata.
It was very likely that he had secondary HTN. K was low despite not taking K wasting diuretics, so initially I thought it might be hyperaldosteronism. However decided to take a shot-gun approach. Serum metanephrines, are a good screening test for pheochromocytoma. Norepinephrine was elevated, and confirmed by 24-h urine collection. The rest of the tests, including cortisol, TSH, aldosterone, renal artery Doppler were negative. The only few studies I found, show no relationship between syphilis and hypertension.
The patient was referred to ID for treatment of latent syphilis/neurosyphilis and to endocrinology for treatment of pheochromocytoma (probably isolated, not part of MEN syndrome).
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