Endocrine Abstracts

Background: Pheochromocytoma (PHEO) is a rare neuroendocrine tumour, classically presenting with hypertension, palpitations and headaches. Some patients have atypical presentations. We report a case of Myocardial Infarction with non-obstructed coronaries (MINOCA) as the key to unravel the diagnosis of PHEO.

Clinical case: A 53-year-old man with type 2 diabetes mellitus and hypertension (under gliclazide MR 60 mg id, bisoprolol 5 mg id, ramipril 5 mg id and atorvastatin 40 mg id), presented in the emergency room with nausea, vomiting, retrosternal crushing pain and palpitations. Over the past year he had frequent hyperadrenergic spells: excessive sweating, thoracic pain, headaches, tremor, pallor, sometimes accompanied by systolic blood pressure over 200 mmHg. Six months earlier, his echocardiogram showed left ventricular hypertrophy and his myocardial perfusion test (scintigraphy) showed abnormalities in the inferior-apical wall, but coronary angiography excluded obstructive coronary disease. CT scan chest revealed a 27 mm left adrenal nodule not typical of an adenoma. Clinical examination was unremarkable with a blood pressure of 107/68 mmHg\. His electrocardiogram showed sinus rhythm with T wave inversion in aVL and elevated troponins: 224 ng/l at baseline and 253 ng/l after 3 h (normal <14 ng/l). Bedside echocardiography was suggestive of stress cardiomyopathy. New coronary angiography showed normal coronary arteries. Patient was managed as MINOCA and underwent Cardiac MRI which revealed mild left ventricle hypertropohy and mild biventricular systolic dysfunction, but no signs of oedema or fibrosis. The clinical evolution was favourable, without symptomatic recurrence. Systolic dysfunction recovered and the patient was discharged (stopped beta-blocker). After discharge, he continued to have daily hyperadrenergic spells. Further investigation revealed raised urine metanephrine 569 µg/24h (<349), noradrenaline of 207 µg/24 h (<89), adrenaline 200 µg/24 h (<19), and plasma metanephrine 346.7 pg/ml (<89). Abdominal CT scan confirmed left adrenal nodule 3 cm compatible with PHEO. We slowly titrated doxazosin which managed to control the spells. MIBG scintigraphy revealed fixation on the left adrenal mass. The patient will undergo laparoscopic left adrenalectomy.

Discussion: This case illustrates the importance of thorough history taking and investigation for the underlying aetiology of an atypical chest pain. Even though the patient presented with classical symptoms over a year, the diagnosis remained elusive. Cardiac complications are an uncommon presentation of PHEO. Early recognition of PHEO is crucial to improve clinical outcomes among these patients.