Endocrine Abstracts

JOINT348

Introduction: Pheochromocytomas can present serious cardiac complications that simulate acute pulmonary edema, arrhythmias, myocarditis, acute coronary syndrome, dilated/hypertrophic cardiomyopathy and takotsubo syndrome. They can also cause neurological complications (PRESS syndrome). The management of adrenergic crises is complicated: intravenous antihypertensives, alpha-antagonists and beta-blockers and in unstable patients, vasopressors.

Objectives: To identify rare cases of pheochromocytoma with severe cardiac pathology diagnosed in our hospital.

Material and Methods: We collected 2 cases of adrenergic crises induced by pheochromocytoma seen in the emergency room, one with a fatal outcome and a postmortem autopsy diagnosis and the other with a satisfactory evolution after adequate diagnosis and treatment.

Results: 1) 53-year-old woman admitted for respiratory distress, chest pain, seizure episode and sudden decrease in level of consciousness. Hypotension, tachycardia and tachypnea. D-dimer 46335, Troponin I 2922.30 and metabolic acidosis. ECG: ST depression on the lower face. Chest X-ray: acute pulmonary edema. Urgent coronary angiography: normal coronary arteries and pattern compatible with stress cardiomyopathy/myocarditis. Echocardiogram: non-dilated LV, mild-moderately depressed systolic function, marked hypokinesia of the basal septum (Takotsubo). Chest CT angiography: cardiac failure, renal infarcts and 46 mm left adrenal mass (adrenal hemorrhage/pheochromocytoma). Hormonal study: Elevated metanephrines.

- Evolution: High doses of norepinephrine and dobutamine are required to maintain blood pressure with severe systolic dysfunction, so levosimendan is started. Pulmonary edema and cardiac function improve, but neurological evolution is poor (head CT - ischemic lesions/vasogenic edema), resulting in death.

- Autopsy: myointimal hyperplasia of coronary arteries. Generalized alveolar edema. Bilateral adrenal hemorrhage, with pheochromocytoma in the left adrenal gland. Heart: changes in the heart muscle typical of infarction, with cardiomyopathy and myointimal hyperplasia of coronary vessels, which could lead to arrhythmogenic changes.

2) 60-year-old male admitted for cardiorespiratory arrest. General malaise, tachycardia, profuse sweating. metabolic acidosis, troponin I 40. ECG: sinus tachycardia and peaked T waves. Chest CT: rules out PE, bilateral pleural effusion and heart failure, left adrenal mass 6 cm. Urgent catheterization: normal coronary arteries. Severely dilated left ventricle (dilated cardiomyopathy), severe hypokinesia (LVEF 15%). Hormonal analysis (urine 24h): elevated metanephrines. Scintigraphy: left adrenal pathological deposit compatible with pheochromocytoma. Cardiac MRI: Non-ischemic dilated cardiomyopathy with severe biventricular systolic dysfunction. Evolution: need for vasoactive drugs with arterial hypertension, alpha and beta blockade is started. After completing the study, surgical resection showed improvement in ventricular function.

Conclusions: Pheochromocytoma may resemble acute coronary syndrome/cardiogenic shock with high mortality, and should be suspected in patients with normal catheterization.