Endocrine Abstracts

Introduction: Rare cases of pheochromocytoma are associated with stress induced Takotsubo cardiomyopathy explained by high catecholamine exposure causing microvascular spasm and direct myocardial impact.

Case report: A 49-year-old female with a history of poorly controlled hypertension, with paroxysmal elevations in blood pressure and rare supraventricular extrasystoles, lipothymic events, was firstly assessed in the cardiologic department. She presented with resistant hypertension, associated with acute pulmonary oedema and cardiogenic shock. Echocardiography revealed new mid LV segment motion abnormality with apical ballooning, ECG – acute ST-segment elevation in the anterior leads and a rise of cardiac biomarkers. The coronary angiography excluded any coronary artery lesion. Thoraco-abdominal CT imaging revealed an 86/85/68 mm left adrenal mass, suggestive for pheochromocytoma. Laboratory evaluation for 24-h urine and plasma catecholamine metabolites disclosed intermediary-low elevated values (plasmatic MN=10/11 pg/ml; plasmatic NMN=59/41 pg/ml, urinary MN=114/881 μg/24 h; urinary NMN=632/1121 μg/24 h), despite high cardiac impact of the spells. She was submitted to 12 days of alpha adrenergic blockade followed by beta blockers, during which control of blood pressure and spells was achieved. Improvement of systolic function (EKG and echocardiography) could be noticed. Laparoscopic adrenalectomy was safely performed without hemodynamic events during surgery or immediately afterwards. Metanephrines and normetanephrines levels normalised with good residual adrenal function. Long term systolic function as well as high blood pressure returned to normal.

Conclusions: Takotsubo cardiomyopathy is associated with reversible LV-ballooning. In this observation, we report a case of stress cardiomyopathy caused by pheochromocytoma; a rare medical condition which is easily confused with acute coronary syndrome due to clinical and biochemical resemblance, especially in our case where plasma and urinary catecholamines were only slightly elevated.