Endocrine Abstracts

Pheochromocytoma commonly presents with headaches, palpitations, sweating and hypertension. However, it can mimic common medical conditions, including septic shock-like syndrome, hyperthermia, pulmonary oedema, and myocardial infarction, making prompt diagnosis difficult.

We present a case of phaeochromocytoma presenting as acute coronary syndrome.

Case report: A 57-year-old woman presented with intermittent, intensifying central chest tightness, nausea, dyspnoea and sweating. Her medical history included Type 2DM, uncontrolled hypertension despite taking 5 different antihypertensive medications, hyperlipidaemia and obesity.

On examination she was clammy, heart rate 130 bpm and blood pressure 194/98 mmHg. Systemic examination was unremarkable.

Serial ECGs during episode of chest pain revealed new T wave inversion/ST segment flattening throughout the precordial leads (V2–V6). Thus acute coronary syndrome was diagnosed and aspirin, clopidogrel and low molecular weight heparin were initiated.

She also had deranged liver function test and CT abdomen revealed 8×6 cm, hypervascular, calcified mass within left adrenal gland associated with local lymphadenopathy suggestive of malignant pheochromocytoma.

Urinary catecholamines were significantly elevated. Troponin I was 0.15 μg/l (Ref. <0.14). Myo-perfusion scan (Adenosine stress test) was normal with no significant inducible ischaemia.

Catecholamine-driven coronary vasospasm was suspected as the cause of acute coronary syndrome. Phenoxybenzamine was started which lead to normalization of blood pressure, resolution of tachycardia and symptoms of chest pain.

Conclusion: We describe an uncommon presentation of pheochromocytoma mimicking acute coronary syndrome. One should maintain high index of suspicion for pheochromocytoma in patients presenting with chest pain, uncontrolled/fluctuating blood pressure, and ischemic electrocardiogram (ECG) changes despite any typical isoenzyme changes. Elevated plasma catecholamines may cause myocardial injury by direct toxic effect on myocytes and/or diffuse coronary vasospasm, in the absence of clinically significant atherosclerotic coronary disease. Quick recognition and diagnosis of phaeochromocytoma is imperative in order to initiate proper therapy.