C76 A PARTICULAR CASE OF MULTIORGAN FAILURE

Abstract

Abstract We reported a case of a 42–year–old man with no major pathologies, symptomatic for a few days for headache, fever and dysuria. For worsening dyspnea and tachycardia the patient was admitted to emergency room. He was markedly hypoxic with severe left ventricular dysfunction, therefore in the suspicion of myocarditis, the patient was centralized in our ICCU. The patient appeared tachycardic (sinus tachycardia 160 bpm), normotensive but hypoperfused (svO2 40%, lac 5 mmol/l, oliguric) and severely hypoxemic despite mechanical ventilation. In the first hours the condition of severe hypoxia persisted (P/F <100), despite optimization of ventilation and curarization, associated with bilateral interstitial edema, marked leukocytosis and PCT> 100. For this reason cultural exams were performed and large spectrum antibiotic therapy started. After about 4 hours the patient was still hypotensive and hypoperfused, despite support with IABP and vasopressors, therefore femoro–femoral VA–ECMO was implanted. There was a rapid improvement of hemodynamic status, peripheral perfusion and reduction of pulmonary congestion but a marked leukocytosis and PCT> 100 persisted with negative cultures. On the 4th day, during ECMO weaning we assisted to wide and rapid pressure fluctuations (SBP from 250 to 60 mmHg in a few minutes). Therefore total body CT was performed in the suspected pheochromocytoma and this showed a necrotized left adrenal mass of about 9 cm and multiple right cerebral hemorrhagic lesions. Therapy with IV alfa–blockers was promptly started and for the marked hemodynamic instability, in the presence of cerebral hemorrhage, left adrenalectomy was performed with removal of the mass approximately 10 hours after diagnosis. In the post–operative phase there was a stabilization of the pressure profile with complete recovery of the biventricular cardiac function, a rapid reduction in inflammation indices and recovery of renal function. The patient gradually recovered to a state of consciousness with residual hemiplegia. Histological examination confirmed the diagnosis of pheochromocytoma. Conclusions The present case represents an example of a catecholaminergic crisis, with fulminant onset and multiorgan dysfunction that initially made diagnosis difficult. Emergency adrenalectomy has conflicting evidence in the literature but in this case it was necessary for pressure instability in the context of cerebral hemorrhage.