A Case of Pheochromocytoma-Associated Takotsubo Cardiomyopathy: Case Report and Review of the Literature

Presentation Number: SAT 390
Date of Presentation: April 1st, 2017

Deepthi Venkat Byreddy*1, Christina M Lovato2 and Matthew Frederick Bouchonville1
1University of New Mexico School of Medicine, Albuquerque, NM, 2University of New Mexico Health Sciences Center, Albuquerque, NM

Abstract

Introduction: Catecholamine-secreting tumors are rare neoplasms, occurring in less than 0.2 percent of patients with hypertension. Pheochromocytoma is a tumor of chromaffin cells that is considered in the evaluation of hypertension, arrhythmias, or panic disorder. Affected patients can present with a classic triad of headache, sweating, and tachycardia. There have been a few case reports of pheochromocytoma and takotsubo cardiomyopathy that have been reported in the literature. We describe a case of pheochromocytoma-associated takotsubo cardiomyopathy that was reversed with medical therapy.

Clinical Case:A 59 year old woman with a history of hypertension (controlled with a thiazide and ACE inhibitor) and prediabetes presented after a motor vehicle collision. She was incidentally found to have a 4.5 x 3.8 x 3.4 cm heterogeneous, enhancing left adrenal mass on the CT scan of the abdomen. She endorsed occasional palpitations but denied headaches, tremors, and diaphoresis.

Blood pressure (119/73 mmHg) and heart rate (76 bpm) were normal. Troponin was elevated at 1.830 ng/ml (reference range: < 0.060 ng/ml) with concern for an anterolateral infarct with ST elevations on EKG. Medical therapy was initiated to treat for possible ischemic heart disease. Transthoracic echocardiogram showed a moderately reduced EF of 31-35% and findings suggestive of takotsubo cardiomyopathy. Cardiology did not perform coronary angiography as the patient was in traction due to C6 and C7 vertebral fractures from the MVC. Additional laboratory studies included plasma fractionated normetanephrines that were elevated at 27 nmol/L (reference range: 0.00 to 0.89 nmol/L) and 24h urine normetanephrines at 7088 ug/d (reference range: 109 to 393 ug/d). Alpha and beta blockade was initiated in anticipation of laparoscopic adrenalectomy. However, the surgery was delayed as the patient required cervical fixation of the vertebral fractures. Repeat transthoracic echocardiogram after 2 weeks of medical therapy showed an improved EF of 70% with resolution of the takotsubo cardiomyopathy. The patient subsequently underwent a left laparoscopic adrenalectomy with surgical pathology confirming a 6.5 cm pheochromocytoma.

Discussion: Takotsubo cardiomyopathy was first described in 1990 in Japan and occurs in approximately 1 to 2 percent of patients presenting with troponin-positive acute coronary syndrome (ACS) or ST-elevation myocardial infarction. This syndrome is characterized by transient regional systolic dysfunction of the left ventricle (LV), mimicking myocardial infarction, but in the absence of angiographic evidence of obstructive coronary artery disease or acute plaque rupture. In this case report we will review the literature describing the occurrence of takotsubo cardiomyopathy and pheochromocytoma as well as the treatment considerations of these two clinical conditions.

 

Nothing to Disclose: DVB, CML, MFB