Phaeochromocytoma as a very rare cause of stress cardiomyopathy: a case report

Phaeochromocytoma is a rare adrenal medullary tumors associated with a chronic or sudden elevation iof catecholamine levels which is almost lethal unless diagnosed early and treated appropriately. Clinical manifestation is mainly caused by circulating catecholamines. Hypertension, ventricular hypertrophy, myocardial infarction, arrhythmias, left ventricular dysfunction, and non-ischemic cardiomyopathy (CM) may develop. We report a rare case of phaeochromocytoma triggering stress cardiomyopathy.

A 71-year-old woman presented with retrosternal chest pain and underwent coronary angiography due to ST elevation acute coronary syndrome (STE-ACS) with Wellens electrocardiography (ECG). Cardiac catheterization revealed patent coronary arteries. Left ventriculography showed LV dysfunction with typical picture of tako tsubo cardiomyopathy with apical ballooning. Within couple of days, the patient's hemodynamic status and left ventricular ejection fraction improved markedly but during the hospital stay she suddenly developed dizziness, sweating, palpitations, pallor and severe fluctuations of blood pressure. Thus, phaeochromocytoma was suspected and was diagnosed using imaging (computed tomography and magnetic resonance imaging) and biochemical (plasma free metanephrines and normetanephrines) investigations. Retroperitoneoscopic right adrenalectomy with radical systematic en block lymphadenectomy was performed. Immuno-histochemical investigations confirmed this finding. After surgery the patient remained hemodynamically stable. Adrenalectomy was associated with a postoperative normotensive state and reduction of antihypertensive medications. She recovered without complications and was discharged from the hospital. In further follow-up examination the adrenal function was intact. The metanephrines and normetanephrines were within the normal range. In addition, we carried out a gene panel for hereditary pheochromocytomas. The result was unremarkable.

We present a rare case of an adrenal tumor in a middle-aged woman that manifested as stress cardiomyopathy. This case shows the importance of identifying differentiated causes of stress cardiomyopathy to prevent patients with rare condictions from relevant morbidities. A presumptive diagnosis of takotsubo cardiomyopathy on cardiac catheterization led to further investigation. Abdominal imaging located an adrenal mass that correlated with high levels of catecholamines and their metabolites. After imaging diagnostics, the phaechromocytoma was excised and the patient recovered without complications.