Abstract 15836: Paraganglioma Presenting as Myocardial Infarction With Decompensated Heart Failure

Abstract

Description of Case: Paragangliomas are extra-adrenal catecholamine secreting tumors, classically presenting with paroxysmal hypertension, headache, and diaphoresis. However, presentations vary significantly, and can mimic cardiac pathologies including myocardial infarction and aortic dissection. A 52-year-old male with history of hypertension and 1 year of palpitations presented for substernal chest pressure with associated dyspnea, nausea and diaphoresis. He reported two days of cough and nasal congestion, and recent addition of metoprolol for palpitations. His family history was notable for early ACS. On examination, he was tachycardic (140 bpm), hypertensive (220/140 mmHg), and hypoxic requiring non-rebreather mask. EKG revealed sinus tachycardia with 1mm J point elevations in V2 and V3. Chest X-Ray and bedside ultrasound indicated pulmonary edema and reduced systolic function. Nitroglycerin infusion was initiated and he was admitted to the Cardiac ICU. Laboratory testing showed a Troponin-T of 0.15 ng/L (normal <0.01 ng/L), ntPro-BNP 2764 pg/mL, lactic acid 3.2 mmol/L, and respiratory swab positive for Influenza A. A CT Aorta ruled out acute dissection but identified several large retroperitoneal masses. Urgent cardiac catheterization demonstrated non-obstructive CAD. Echocardiography noted severely reduced ejection fraction of 30-35%. With diuresis and alpha blockade, he clinically improved and was discharged. Plasma and urine studies revealed elevated metanephrines. He underwent open paraaortic mass resection and pathology later confirmed paraganglioma. Discussion: With angina, elevated troponins, and acute decompensated heart failure, this presentation was initially concerning for ACS. However, the absence of obstructive CAD warranted further investigation. While concomitant Influenza A infection raised concern for viral myocarditis, abdominal imaging proved crucial in diagnosing paraganglioma.