Abstract 13939: Catecholamine-Induced Cardiomyopathy and Limb Ischemia in Pheochromocytoma

Abstract

Case Presentation: A 40-year-old woman who was 4 weeks pregnant presented with nausea and vomiting. Blood pressure (BP), heart rate, and temperature were 180/104 mmHg, 85 beats/min, 36.1℃ (96.98 ℉), Hypoxemia and mild pulmonary edema were observed. Echocardiography showed severe left ventricular dysfunction and normal dimension with ejection fraction < 10 %. As BP was decreased despite inotropic agents with aggravated hypoxemia, deteriorated acute kidney injury, mechanical ventilation, venous arterial extracorporeal membrane oxygenation (VA-ECMO), and continuous renal replacement therapy were initiated. Coronary angiography revealed normal coronary arteries and the possibility of myocarditis was low because endomyocardial biopsy showed rare inflammatory infiltration. After a few days, other parameters including cardiac function were improved and VA-ECMO was stopped, however, ischemic signs of the right lower leg progressed. To rule out rhabdomyolysis and compartment syndrome, CT angiography was done and about 4.9 cm sized left adrenal mass was found (A). The results of catecholamines are as follows: plasma metanephrine, 1862.6 (< 98.6 pg/mL); normetanephrine, 993.8 (< 164.9 pq/mL); 24hr urine metanephrine, 1396.2 (36~229 mcg/24hr); normetanephrine, 835.8 (95~650 mcg/24hr). A diagnosis of pheochromocytoma was made and left adrenalectomy was done, Pheochromocytoma was demonstrated in biopsy. Unfortunately, due to severe vasoconstriction and rhabdomyolysis, her right leg was not completely recovered, so amputation was done below knee (B). Discussion: Pheochromocytomas are catecholamine secreting tumors derived from chromaffin cells in the adrenal medulla. Catecholamine-induced vasoconstriction, microvascular hypoxia, muscle ischemia, direct toxic effects are considered to contribute to cardiomyopathy and limb ischemia in rare situations. Timely clinical suspicion, prompt diagnosis, and therapeutic intervention are critical.