Q: 21 year old male presented to ER with palpitations, sweating and headache. He was found to be hypertensive in ER. Urine tox screen was negative. Patient BP was unresponsive to Cardene drip and is admitted to ICU. On history taking, patient informed you that his symptoms started while night out with friends, drinking lot of wine, imported beer and eating huge amount of smoked meat. Patient is taking anti-depressant at home. You suspect pheochromocytoma but patient informed you that he has been worked up in past and is ruled out for pheochromocytoma? 



Answer: 

Combination of a monoamine oxidase (MAO) inhibitor drugs and the ingestion of tyramine-containing foods may produce symptoms similar to pheochromocytoma.

Major MAO inhibitors include antidepressant drugs tranylcypromine, phenelzine, and isocarboxazid. Foods contain relatively high concentrations of tyramine fermented cheeses, imported beer, Chianti, champagne, some wines, soy sauce, avocados, bananas, and any fermented, smoked, or aged fish or meat. These food should be avoided by patients on these antidepressants. Tyramine, which is produced from the bacterial breakdown of tyrosine, is normally inactivated by MAO in the intestinal tract. This inactivation does not occur in the presence of an MAO inhibitor, leading to the absorption of tyramine, which increases the release of norepinephrine from nerve endings and epinephrine from the adrenal gland.