Endocrine Abstracts

Hypertension is the most commonly recognised cardiac manifestation of a phaeochromocytoma. There are however a variety of other cardiac presentations including arrhythmias and the increasingly reported Takotsubo cardiomyopathy. We present the case of a female patient presenting acutely to the general medical take who was found to have cardiac arrhythmias and transient left ventricular dysfunction.

The initial presentation was breathlessness, chest pain, sweating, and clamminess. Investigations performed on admission demonstrated elevated troponin and dynamic ECG changes (sinus tachycardia with frequent ventricular ectopics and later developed profound anterior T wave inversion from V3 to V6). The working diagnosis was acute coronary syndrome and pulmonary oedema. She underwent cardiology work up including an echo and coronary angiography. The echo was technically difficult due to her tachycardia, but the coronary angiogram showed normal coronary arteries. Her clinical condition deteriorated with labile blood pressure (range 239/129–48/34) and arrhythmias, the possible diagnosis of a phaeochromocytoma was suggested.

Further investigations included; plasma metanephrines and normetanephrines which were significantly elevated (25 000 pmol/l (normal range <510), 18 568 pmol/l (120–1180) respectively), and CT scan demonstrated a 13 cm right adrenal mass, confirming the diagnosis of phaeochromocytoma. Owing to the paroxysmal hypertensive/hypotensive instability intravenous phentolamine was initially used to stabilise her blood pressure. This was then converted to doxazosin, with β-blockers being added prior to discharge. Owing to a pulmonary embolism requiring treatment, the need to improve her overall health status, and instability on the operating table requiring cancellation of the first attempted procedure, the surgery to remove the phaeochromocytoma was delayed. At the second attempt surgery was successful and she made an uneventful recovery.

The case identifies various life-threatening cardiac manifestations of phaeochromocytoma and medication that was used during an acute presentation with a successful outcome.