Endocrine Abstracts

Background: Takotsubo cardiomyopathy (TTC) is a type of non-ischemic cardiomyopathy typically induced by emotional or physical stress. Patients commonly present with symptoms mimic those of acute coronary syndrome with normal coronary vessels. Characteristic findings include transient dilatation and dysfunction of left ventricle. TTC has recently been recognized to occur due to various physical stressors, including excess of catecholamine such as pheochromocytoma/paraganglioma. Cardiomyopathy was reported in 11% of cases of pheochromocytoma /paraganglioma (PGL).

Case description: Our case presents a unique scenario involving a 62-year-old woman with a history of well controlled hypertension (on ramipril) and newly type 2 diabetes. She presented to same day emergency care, with severe vomiting over four days without chest pain, initially diagnosed with acute kidney injury. Her ECG showed global T-wave inversions, and troponin levels raised to 1624 ng/l. A bedside echocardiogram revealed a dilated left ventricle with global dyskinesia, leading to a diagnosis of myocarditis and transfer to the cardiac unit. Subsequent cardiac angiography indicated normal coronary arteries. MRI cardiac revealed features of stress cardiomyopathy and incidental adrenal lesion measuring approximately 6.7 cm. Plasma metenaphrine was>25000 pmol/l Normetanephrine >25000 pml/l, raising the suspicion of pheochromocytoma-induced cardiomyopathy. She developed a hypertensive crisis due to unopposed beta-blockade after being started on carvedilol for left ventricular failure. Once transferred to the endocrinology ward, her symptoms resolved completely after discontinuing carvedilol and initiating doxazosin, which was gradually titrated up to 4 mg per day. She was later reintroduced to carvedilol at a dose of 12.5 mg. Her systolic blood pressure remained well-controlled, under 120 mmHg, with manageable postural hypotension. MIBG later showed appreciable uptake in left adrenal. A plan was made for a laparoscopic adrenalectomy.

Discussion: This case report highlights the importance of considering paheo/paraganglioma. As a cause of Tabkotsubo /stress cardiomyopathy even with atypical presentation.