Endocrine Abstracts

Case history: A 75-year-old lady presented with sudden central chest discomfort to Emergency Department. The chest pain was preceded by palpitations. She had a background of Hypertension. She was non-smoker and otherwise fit and well. She mentioned receiving a steroid injection one day ago for joint pain. Her B.P on presentation was 226/106. Her physical examination was otherwise normal.

Investigations: Her ECG on admission revealed atrial tachycardia and ST depression in anterior chest leads. She was admitted under cardiology team who started her on beta blockade for atrial tachycardia. CT aortogram was organised to rule out aortic dissection. Aortic dissection and large pulmonary embolism were ruled out by CT but an incidental complex cystic abnormality was seen behind the stomach which was deemed unrelated to her condition at the time. Her lab Troponin levels were 270 (on admission), 1877 (5 h), 2462 (7 h post admission). Her Echo revealed severely reduced Ejection fraction 35% and inferolateral hypokinesia. Her chest pain continued and she then developed new ST elevation 3 h post admission. At this point,she was started on ACS treatment and taken to cath lab for PCI. On angiography, no blockade amenable to PCI was found so no procedure could be performed. Patient then developed severe pulmonary edema post PCI and needed CPAP. Cardiology team considered phaeochromocytoma as cause of patient’s symptoms (in view of cystic mass found on CT) and endocrinology review was sought.

Results and treatment: CT abdomen and 3 collections for urinary catecholamine metabolites levels were performed on endocrinology advice.

CT abdomen revealed 5 cm part-solid, part-cystic mass.

Urinary Levels were as below:

–  Urinary metadrenalines 34.61

–  Nor-metadrenalines 33.15

–  3 methoxy tyramine urinary: 3.15

Based on above results, she was diagnosed with Phaeochromocytoma.

Patient was referred to tertiary endocrine surgical centre for surgery. She underwent removal of a left adrenal phaeochromocytoma 3 months later. Her PASS score was 6/20, indicating borderline phaeochromocytoma with potential for recurrence. Her genetic analysis did not reveal any phaeochromocytoma/ paraganglioma susceptibility gene.

Conclusion and points for discussion: This was a challenging case as initial presentation matched acute coronary syndrome and beta blockade was started which likely led to pulmonary edema and worsening of symptoms. It should be borne in mind that Phaeochromocytoma can present as acute coronary syndrome and should be considered among differentials in unexplained acute coronary syndrome. The possibility of recent intra-articular steroids injection in precipitating phaeochromocytoma crisis should be considered.