a paraganglioma , or pheochromocytoma , presenting with myocardial infarction ( mi ) is rare . we report a case of a non - hypertensive asymptomatic male without coronary artery disease who presented with an mi likely associated with a paraganglioma causing end organ ischemia . conclusions / summary : uncommon etiologies of mi may be encountered in emergency department ( ed ) settings . a 49-year - old male , parachute instructor by profession , presented to the ed with complaint of non - radiating substernal chest pain following chute deployment . during the episode , he noted associated headache , diaphoresis , and palpitations , which subsequently spontaneously resolved after landing . the parachute jump was described as standard : the patient denied significant environmental conditions , such as a high altitude jump or extreme cold exposure . there was no change in intensity , location , or character of his pain during the remainder of his parachute ride to landing . his pain was described as dull , non - radiating , and rated 7/10 improving to a 5 - 6/10 . no prior history of similar chest pain , associated shortness of breath , nausea , change in sensation , or weakness was reported . the patient did admit to a history of gastroesophageal reflux and was intermittently compliant with his prescribed ranitidine . the patient arrived to the medical center via his private vehicle . upon presentation , the glasgow coma scale ( gcs ) was 15 with pulse of 80 , blood pressure ( bp ) of 132/87 , respirations of 16 , temperature of 100.5 degrees fahrenheit , and room air saturation of 96% . the ed management included sublingual nitroglycerine , which resolved his chest pain after one dose , followed by nitroglycerine paste and aspirin . [ figure 1 ] differential diagnosis included a traumatic aortic dissection , so a cardiac gated computed tomography ( ct ) was obtained that did not demonstrate this etiology as a source for his chest pain . however , an incidental retroperitoneal mass below the level of the left kidney was discovered , which appeared to be highly vascular , with central necrosis , and had at least one feeding artery coming directly off of the aorta [ figure 2 ] . he was started on low weight molecular heparin with clopidogril and admitted for further observation to the cardiac intensive care unit with a planned diagnostic cardiac catheterization . the catheterization showed no angiographic evidence of coronary artery disease ( cad ) and normal left ventricular function . over the course of the hospitalization the patient 's bp was intermittently hypertensive without report of associated chest pain . a neuroendocrine work - up for the para - aortic mass demonstrated a normal catecholamine metabolites , normetanephrine ( 329 mcg/24 hours [ reference range : 88 - 649 mcg/24 hours ] ) and metenephrine ( 164 mcg/24 hours [ reference range : 58 - 203 mcg/24 hours ] ) on 24-hour urine . electrocardiograms ( 1 [ symptomatic ] and 2 [ asymptomatic ] during ed stay ) ct demonstrating para - aortic mass later found to be a paraganglioma the patient was discharged home with atenolol and atorvastatin after a four - day hospitalization . intravenous fluids , phentolamine , and metoprolol were utilized for presurgical treatment in this patient . he returned to his profession as a full - time parachute instructor three months later and subsequently discontinued antihypertensive medications . this case illustrates an unusual cause of mi , rarely reported in the literature.[14 ] extra - adrenal pheochromocytomas , better known as paragangliomas , are neuroendocrine tumors that produce , store , and secrete catecholamines . these neoplasms may occur in all age groups but are most common in young and middle - aged adults . hypertension is the most common sign , and hypertensive paroxysm , or crisis , occurs in more than half of all cases . hypertensive crises may be precipitated by any activity that displaces the abdominal contents , and tachyarrhythmias are the most common cardiac manifestation . angina and acute myocardial infarction may occur in the absence of coronary artery disease due to increased oxygen consumption , coronary spasm , and increased afterload contributing to ischemia . signs and symptoms of paraganglioma / pheochromocytoma diagnosis may be made from elevated plasma catecholamines metabolites , only if drawn during a hypertensive crisis . a 24-hr urine sample may demonstrate increased excretion of metanephrine , normetanephrine , and vanillymandelic acid ( vma ) . treatment of associated hypertension is with phenoxybenzamine , an irreversible alpha - blocker with a long half - life . hypertensive emergencies may be treated with intravenous phentolamine before adequate alpha - blockade is achieved . nitroprusside , calcium channel blockers , and angiotensin - converting - enzyme inhibitor ( ace ) inhibitors will also reduce blood pressure in these patients . five - year survival after surgery is usually over 95% , and the recurrence rate is under 10% . removal of tumor cures hypertension in the majority of patients though residual tumor may cause persistent symptoms . patients with persistent hypertension after tumor resection may be managed with standard anti - hypertensive therapy . primary care follow - up includes 24-hour urine , which should be reassessed annually , even in asymptomatic post - surgical patients . this case shows that cardiac chest pain leading to a myocardial infarction may be the initial manifestation of a paragangliomas in the absence of prior symptoms or significantly elevated blood pressure .
paragangliomas , extra - adrenal pheochromocytomas , are rare and classically associated with sustained or paroxysmal hypertension , headache , perspiration , palpitations , and anxiety . 
 a 49-year - old male , parachute instructor , likely developed a hypertensive emergency when deploying his parachute leading to a myocardial infarction . 
 a para - aortic tumor was incidentally discovered during the patient 's emergency department work - up and was eventually surgically resected . 
 he had no evidence of coronary disease during his evaluation . 
 this case shows that a myocardial infarction may be the initial manifestation of these neuroendocrine tumors . 
 hypertensive emergency , much less elevated blood pressure may not be present at time of presentation .