Endocrine Abstracts

Introduction: This is a case of fulminant adrenergic myocarditis (FAM) in a young gentleman with catecholamine storm.

Case presentation: A 24-year-old gentleman with cannabis misuse, otherwise fit, presented with nausea and abdominal pain. Although his observations and glucose levels were normal on admission, shortly thereafter, he exhibited an acute onset of hypertension (180/130 mmHg), tachycardia (160/min), hyperglycaemia (CBG >27.8mmol/l), and ketonaemia (2.6mmol/l). Within hs, he developed cardiovascular collapse (BP 65/40mmHg) with acute heart failure and cardiogenic pulmonary oedema, requiring ITU support with inotropes, pressors and ventilation. VBG showed severe metabolic acidosis (pH 7.042, bicarbonate 9.9) with hyperlactatemia (14mmol/l). Hyperglycaemic ketosis in non-diabetic gentleman was considered secondary to stress response or catecholamine storm and was treated with intravenous insulin. Serial echocardiograms showed consistently low LVEF (<30 %). Troponin-T and NT-pro-BNP were elevated: 591ng/l and 20,056ng/l, respectively. Once stabilised, heart failure management initiated. Cardiac MRI three weeks post-admission showed improving LVEF (49%), diffuse myocardial oedema and mid-wall patchy fibrosis, suggestive of fulminant myocarditis. Follow-up cardiac MRI (3 months) showed LVEF 64% with no RWMA or fibrosis. Post-discharge, the endocrine team organised plasma-free metanephrines, which were essentially normal. Noted no evidence of PPGL on CT-CAP.

Discussion: Acute presentation with hypertension, tachycardia, and hyperglycaemia suggested catecholamine storm. Subsequent cardiogenic shock with typical MRI appearance led to the diagnosis FAM secondary to cannabis use. FAM causes myocardial inflammation leading to severe LVSD and cardiogenic shock. Catecholamine excess, from PPGL or drugs (cannabis/stimulants), is a potential trigger. Prolonged adrenergic stimulation causes receptor desensitisation and myocardial stunning. Hence, LVSD can be reversible. Catecholamines stimulate glycogenolysis/gluconeogenesis, inhibit insulin secretion, and impair glucose uptake, causing hyperglycaemia.

Conclusion: A catecholamine storm does not always indicate an endocrine tumour. While PPGL is a classic cause, other non-endocrine causes should also be considered, as they can cause an identical clinical picture.