Endocrine Abstracts

A 47-year-old businessman was admitted to the cardiology ward with a 3-week history of worsening dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea and swollen ankles. Clinical examination revealed sinus tachycardia, hypertension (190/100 mmHg), bibasal crepitations and ankle oedema. CXR showed cardiomegaly and pulmonary oedema while ECG showed left ventricular hypertrophy. Renal function and blood–glucose were normal. He was commenced on diuretics. Echocardiogram noted severe left ventricular dysfunction with ejection fraction of less than 25%. Angiogram excluded coronary artery disease. During his stay, his BP fluctuated enormously, with the peak reading of 220/140. Renal ultrasound scan done in view of severe hypertension suggested a left-sided renal mass, and CT scan confirmed the presence of an 8 cm adrenal lesion. Twenty-four hour urinary catecholamine levels were consistently elevated and MIBG study revealed abnormally high tracer-uptake in the left adrenal mass. A diagnosis of left sided phaeochromocytoma was made; phenoxybenzamine was started and gradually titrated up to 60 mg, together with gradually increasing dose of Atenolol up to 100 mg daily. Both BP control and cardiac function improved (ejection fraction 50–55%). The tumour was surgically removed without complications. Post-operatively, urinary catecholamine concentration returned to normal range, and MIBG scan revealed no residual tumour. Hypertension however persisted, needing treatment.

Phaeochromocytomas (intra-adrenal paragangliomas) are uncommon tumours, mostly presenting with paroxysmal or persistent hypertension. Rarely, cardiac clinical features predominate, such as angina, arrhythmias, acute myocardial infarction, myocarditis and catecholamine-cardiomyopathy. Combined alpha- and beta-adrenergic blockade of catecholamine-effects in our patient resulted in a significant improvement of cardiac performance even prior to surgery. Despite complete excision of the tumour and being disease-free, he remained hypertensive – an observation seen in nearly 50% of cases. Our report highlights the importance of recognizing the cardiac manifestations of phaeochromocytoma, with good outcome following appropriate management.