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Endgames Picture Quiz

A woman with episodic headaches, sweating, and palpitations

BMJ 2011; 342 doi: (Published 29 June 2011) Cite this as: BMJ 2011;342:d2977
  1. Angus Jones, specialist registrar1,
  2. Matthew Bull, specialist registrar2,
  3. Bijay Vaidya, consultant endocrinologist and honorary reader1
  1. 1Department of Endocrinology, Royal Devon and Exeter Hospital, Exeter EX2 5DW, UK
  2. 2Department of Radiology, Royal Devon and Exeter Hospital
  1. Correspondence to: B Vaidya bijay.vaidya{at}

A 39 year old woman was referred to the headache clinic with a 10 year history of episodic headaches, sweating, and palpitations. The symptoms had intensified over the past one to two years. Since then she has been experiencing three to four episodes a day, mostly at night, of severe headache, chest tightness, sweating, palpitations, and “churning stomach.” She had no medical history of note and took no regular drugs. Her mother had been diagnosed with metastatic cancer of unknown source in her early 60s.

On examination, her blood pressure was 100/80 mm Hg, with no postural drop; pulse was 86 beats/min and regular. She had a palpable left thyroid nodule but no associated lymphadenopathy, and other systemic examinations were unremarkable.

Magnetic resonance imaging of the head showed no abnormalities. Thyroid function tests were normal; 24 hour urinary catecholamines performed twice showed markedly raised noradrenaline (628 nmol/L and 613 nmol/L; reference range 0-450) and adrenaline (722 nmol/L and 915 nmol/L; 0-100), suggestive of phaeochromocytoma. Magnetic resonance imaging of the adrenals showed a large mass in the right upper quadrant and a small mass in the left adrenal. An iodine-123-meta-iodobenzylguanidine (123I-MIGB) single photon emission computed tomography (SPECT) scan (fig 1) was performed.

Fig 1 Coronal 123I-MIBG SPECT fusion scan


  • 1 What does the 123I-MIBG SPECT scan show?

  • 2 What is the possible importance of the thyroid nodule?

  • 3 What further investigations would you perform?

  • 4 How would you manage this patient?


1 What does the 123I-MIBG SPECT scan show?

Short answer

The 123I-MIBG SPECT scan shows increased uptake of marker in the right upper abdomen, and in the regions of the left adrenal gland and left thyroid lobe.

Long answer

MIBG is a precursor of catecholamines. Radiolabelled 123I-MIBG or 131I-MIBG enters the catecholamine synthesis pathway and concentrates within phaeochromocytomas and other neuroendocrine tumours.1 In suspected …

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