Endocrine Abstracts

Introduction

Pheochromocytomas are rare catecholamine-producing neuroendocrine tumors derived from the sympathetic or parasympathetic nervous system. The clinical presentation of pheocromocytoma has varying forms, which makes diagnosing it challenging. Here, we report a case of Adrenergic cardiomyopathy mimicking COVID-19.

Case report

A 40-year-old woman with a history of pulmonary edema during cesarean delivery 4 years ago with an ad integrum normalization of cardiac function was admitted to the emergency for acute shortness of breath. Three days before her admission she presented epigastralgia, vomiting and myalgia. On physical examination: temperature: 37.9°C, blood pressure: 100/60 mmHg, HR:100 bpm, peripheral oxygen saturation 100% with oxygen therapy at 15 l/min. The chest CT revealed bilateral asymmetric ground glass opacities extended to the 2 pulmonary fields, lobe and interseptal thickening, that could be compatible with covid-19 pneumonia. The day following the admission, the patient presented an acute chest pain with tachycardia, peripheral oxygen saturation 88% with oxygen therapy at 15 l/min, confusion and eventually a cardiac arrest. The patient was successfully resuscitated, intubated, and mechanically ventilated. The electrocardiogram showed a sinus tachycardia at 110 bpm with ST segment depression in the infero-lateral leads. Transthoracic echocardiography (TTE) revealed left ventricular septal hypokinesis with ejection fraction (LVEF) 40%. Blood examinations returned the following values: troponin: 9 ng/ml;BNP: 1558 pg/ml. The diagnosis of myocarditis was brought up: hypoxemia, localized depolarization disorder, echocardiographic findings and abnormal cardiac biomarkers. A second chest scan has showed the disappearance of ground-glass opacities. The Sars-Cov2 pneumonia was eliminated because of a negative PCR, serologies and the quick disappearance of the ground-glass opacity. An abdominal computed tomography showed a liquid mass on the left adrenal gland, measuring 5.2 × 4.6 cm, with well-defined borders thickened in places. After the improvement of her condition, the patient was extubated and referred to the endocrinology department for further exploration. Holter monitoring of blood pressure has eliminated any hypertensive peaks. Laboratory tests of urine catecholamines metabolites showed increased Normetanephrine (1.3 the standard level), but normal metanephrine. A second TTE revealed a normal heart function: FEVG 70 %. Cardiac MRI, performed 16 days after, was normal. Left surrenalectomy was performed. Histopathological evaluation confirmed the diagnosis of pheochromocytoma.

Conclusion

Pheochromocytoma can present itself with normotensive cardiomyopathy. Adrenergic cardiomyopathy is a rare entity with a variable clinical presentation. This case demonstrates the importance of considering pheocromocytoma in cases of myocarditis without a cardiac etiology.