A DIRE WOLF IN WOLF'S CLOTHING

Abstract

Objective: Takotsubo cardiomyopathy is often attributed to women over 60 years of age as a result of an emotional event stress. Pheochromocytoma is a rare etiology that can mimic Takotsubo cardiomyopathy through hypersecretion of catecholamines. This case is that of a patient presenting with atypical Takotsubo cardiomyopathy fortuitously discovered in a context of intense paroxysmal migraine. Design and method: A 38 year old female patient with a medical history of migraine, depression, anorexia, and an active smoking attends the emergency for frontal-orbital migraine headache, bilateral otalgia and myodesopsia. arterial blood pressure at 175/95 mmHg,The patient received analgesic treatment and a cerebral CT scan was performed with a normal outcome. Her ECG showS incidental findings of ST depression in V1-V2 and negative T waves in upper lateral leads(DI, AVL). HS troponin levels are elevated. The patient received a triple antithrombotic therapy transferred to our hospital for emergency coronary angiogram. Upon arrival, the patient is asymptomatic, BP 145/75 mmHg, and received emergency coronary angiogram revealing a healthy coronary artery up and the ventriculography detected a ballooning of the left ventricle. TTE findings are an altered LVEF estimated at 40%, apical akinesia and hypokinesia of the adjacent segments, an apical ballooning. The rest of the TEE is normal. Takotsubo is evoked. hospitalization is marked by a normalization of the patient's ECG. 2 days after the coronography, the patient presents with intense recurrence of migraines, ST depression on leads V1-V2 and a severe hypertensive crisis at 220/160mmHg. After initiating an IV antihypertensive treatment, there is a regression of the symptomatology and electrocardiographic changes. Results: Atypical Takotsubo associated with HTN crisis resulted in the panel of secondary HTN. CT scan findings show an adrenal mass. The normetanephrine values and total metanephrine values are elevated. These elements are in favor of a pheochromocytoma. Conclusions: The patient presented an atypical picture of ACS. The initial diagnosis associated with paroxysmal hypertensive flare-ups are the result of an underlying pheochromocytoma. It is important not to settle for a diagnosis of exclusion without mentioning all possible etiologies and thus reduce the morbidity and mortality of this pathology.