High metanephrines with adrenal hemorrhage: a diagnostic dilemma.

Adrenal hemorrhage (AH) may mimic hemorrhagic pheochromocytoma, particularly with markedly elevated plasma metanephrines. We report a 39-year-old woman who presented with acute right-sided abdominal pain, falling hemoglobin, and right AH on computed tomography (CT). Plasma metanephrine and normetanephrine were elevated above 3 times the upper limit of normal, raising concern for a hemorrhagic pheochromocytoma. Adrenal arteriography confirmed active hemorrhage and the vessel was successfully embolized. The day after embolization, metanephrines normalized, and adrenocortical function was intact. At 6 months, she remained asymptomatic, with normal dexamethasone suppression test and stable hematoma on CT. This case illustrates that markedly elevated metanephrines in the acute setting of AH may reflect physiologic stress rather than autonomous catecholamine secretion.