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Cardiac Manifestations of a Phaeochromocytoma CJH May, N Gittoes, A Toogood, J Ayuk Figure 6.
Introduction We present the case of a patient with chest pain, cardiac arrhythmias and transient left ventricular dysfunction leading to a diagnosis of phaeochromocytoma.
Case Report • 74 year old Afro-Caribbean female, • Acute presentation with breathlessness, chest pain, sweating and a productive cough with green sputum (10th August 2013) • Past medical history included type hypertension and hypercholesterolemia
2
diabetes
mellitus,
• On admission found to have elevated troponin and dynamic ECG changes (figure 1 & 2) • Working diagnosis: Acute coronary syndrome with pulmonary oedema and probable lower respiratory tract infection
Management: • Haemodynamic stabilisation using intravenous phentolamine • Conversion to doxazosin, with beta blockers later added • Follow up Cardiac MRI demonstrated resolution of left ventricular dysfunction • Resection of the phaeochromocytoma, initially delayed 1. Allowed time for improvement in overall health and fitness for surgery 2. Patient diagnosed with a pulmonary embolism, required 6 months anticoagulation
Figure 2. ECG 12th August 2013.
• Post operatively uneventful recovery, with discontinuation of diabetic and antihypertensive medication • Histology confirmed phaeochromocytoma, maximal dimension was 22 cm, PASS score 8 and the Ki-67 2%
Figure 1. ECG 9th August 2013.
• Echo technically difficult due to tachycardia • Coronary angiogram showed normal coronary arteries • Clinical condition deteriorated with labile blood pressure (range 239/129 to 48/34) and arrhythmias, requiring chemical and electrical cardioversion (see figure 3 & 4) Figure 3, Observations.
Discussion Cardiac complications of phaeochromocytoma include: • Hypertension+/- hypertensive crisis • Hypotension and shock • Arrhythmias e.g. sinus tachycardia, AF, broad complex arrhythmias, VT and VF • Catecholamine induced cardiomyopathy (Takotsubo Cardiomyopathy) due to catecholamine surge, resulting in a transient cardiomyopathy (3) • Myocardial ischaemia and infarction • Pulmonary oedema • Left ventricular hypertrophy • Myocarditis (1,2,3)
Figure 5.
The diagnosis of phaeochromocytoma was confirmed by: • Elevated plasma metanephrines (25000 pmol/L (normal range
