No abstract

No abstract

No abstract

A 57-year-old woman presented with acute pulmonary oedema after experiencing sudden onset headache, vomiting and chest discomfort with palpitations after dinner. There was no focal neurological deficit. Her only history was that of hyperlipidaemia treated with statin therapy, and osteoporosis with a recent low-intensity fracture of the ankle. She was in cardiogenic shock and was commenced on non-invasive ventilation, diuretics and inotropic support with noradrenaline.Electrocardiogram showed a sinus tachycardia with presumed new left bundle branch block. Creatinine kinase was increased at 2630 IU/L (normal < 195 IU/L) and troponin T was increased at 6.5 ng/mL (normal < 0.01). Pro-brain natriuretic peptide was increased at 1939 pmol/L (0-29.1). There was a profound metabolic acidosis with partial respiratory compensation, and hyperglycaemia in the absence of ketonaemia or ketonuria, which normalized without treatment. Emergent coronary angiography showed normal epicardial coronary blood flow. Left ventriculography revealed akinetic mid to basal segments with a hyperkinetic apex and mild mitral regurgitation because of regional wall motion abnormality. This inverted/reverse pattern of hypokinesis was the opposite of the usual one of apical hypokinesis seen with Takotsubo cardiomyopathy (Fig. 1). There was rapid improvement within 4 days and normalization of regional wall motion and absence of mitral regurgitation. At 6 weeks after the index event, serum adrenaline levels were increased (666 nmol/day (5-80)), as well as urinary metanephrine excretion rate (10 micromol/day (Յ2.1)), while serum noradrenaline, fasting blood sugar, calcitonin and electrocardiography were normal. Computed tomography scan of the abdomen showed a 30 mm ¥ 25 mm diameter tumour of the right adrenal gland. A metaiodobenzylguanidine scan was suggestive of localized involvement of the right adrenal gland only. Phenoxybenzamine was commenced and laparoscopic adrenalectomy was successfully performed 1 month later. Histopathology confirmed a diagnosis of phaeochromocytoma.Takotsubo cardiomyopathy, although uncommon, is being increasingly reported in the literature as a cause of acute cardiac failure in middle-aged women. It is seen in 2% of all patients presenting with chest pain and segment elevation. Patients experience chest pain with electrocardiogram changes consistent with acute myocardial infarction but have normal underlying epicardial coronary blood flow and characteristically have severe hypokinesis of the apex with a hyperkinetic basal heart. 1,2 A pattern of basal hypokinesis and apical hyperkinesis referred to as inverted Takotsubo has now been recognized and was seen in this case. The pathogenesis of Takotsubo cardiomyopathy has been linked to an excess of catecholamines. 3,4 Pheochromocytoma is a rare tumour derived from chromaffin cells secreting an excess of norepinephrine and epinephrine and rarely dopamine. Its reported incidence is 0.05-0.2% of hypertensive individuals. Association of phaeochromocytoma with an inverted Takotsub...