SAT333 A Case Of Pheochromocytoma Initially Presenting As Takotsubo-like Cardiomyopathy

Abstract

Abstract Disclosure: J.S. Figueroa: None. S.W. Holland: None. J. Cheng: None. M.C. Sullivan: None. Background: Takotsubo-like cardiomyopathy (TCM) is a known but rarely seen clinical complication associated with pheochromocytoma that is important to recognize. Case Presentation: A 68 year old woman with a history of hypertension on verapamil, lisinopril-hydrochlorothiazide, clonidine, hyperlipidemia, asthma, and chronic kidney disease presents for nausea and vomiting associated with pressure like chest pain. Cardiac work up revealed elevated troponins and T wave inversion in the anterolateral leads concerning for non-ST segment elevation myocardial infarction (NSTEMI). CT Abdomen study revealed two right sided adrenal nodules 2.4 x 1.8 cm and 1.9 x1.1 cm. Coronary angiography was normal but study was concerning for TCM. She developed new onset atrial fibrillation and was treated with calcium channel blocker and beta blocker. Transthoracic echocardiography showed apical hypokinesis and a mildly decreased ejection fraction of 41%. She was discharged home on beta blocker and losartan therapy. The patient presented 5 days later with similar symptoms and a maximum elevated blood pressure 170/110 mm Hg. Labs revealed elevated plasma free metanephrines level of 505 pg/ml (ref range ≤57 pg/ml) with normal renin, aldosterone, and cortisol levels. CT adrenal protocol study showing pre-contrast density of largest nodule 39 Hounsfield units (HU), postcontrast density 81 HU, and washout density 56 HU with washout at 59.5%. The smaller nodule had pre-contrast density of 31 HU, postcontrast of 65 HU, washout density of 61 HU with washout at 11.8%. Endocrine and Endocrine surgery were consulted at this time. Alpha blocker tamsulosin was initiated and beta blocker therapy was discontinued. Patient underwent right adrenalectomy with subsequent improvement of her ejection fraction two months later. Histology was concerning for malignancy for which she is currently being followed. Conclusion: This case highlights TCM as a presenting sign for a pheochromocytoma. A study by Agarwal et al. found that a minority of patients who had TCM due to pheochromocytoma developed symptoms typical of the tumor such as headache, hypertension, palpitations, and diaphoresis. The study also found that complications such as cardiogenic shock and heart failure were higher in pheochromocytoma related TCM.¹ Consider catecholamine producing tumors as a potential cause of TCM where appropriate alpha and beta blockade may help to reduce symptoms. Earlier recognition of a potential pheochromocytoma would also have discouraged the use of a beta blocker initially until pheochromocytoma was ruled out. An individualized, multidisciplinary approach helps lead to a timely diagnosis and appropriate treatment decisions for these rare tumors. References (1) Agarwal, V.,Kant, G.,Hans N., Messerli F.H. Takotsubo-like Cardiomyopathy in Pheochromocytoma. International Journal of Cardiology 2011; Vol 153,3,241-248 Presentation: Saturday, June 17, 2023