Phaeochromocytoma found on cardiovascular magnetic resonance in a patient presenting with acute myocarditis: an unusual association

Abstract

Myocarditis is inflammation of the cardiac muscle. The symptoms, signs and basic investigation findings can mimic that of myocardial infarction. The most common cause is infection (most commonly viral). Cardiovascular magnetic resonance (CMR) is the gold standard non-invasive diagnostic test for potential acute myocarditis as it allows assessment of myocardial oedema and scar. A man aged 25 years was admitted with chest pain, dizziness, headache, palpitations and sweating. His troponin was mildly positive. A CMR was performed which showed mild myocarditis and a right suprarenal mass which was confirmed to be a phaeochromocytoma based on biochemistry and a dedicated imaging workup. Phaeochromocytoma can lead to cardiac involvement in the form of left ventricular dysfunction, or catecholamine-induced myocarditis.

Cardiovascular Manifestations and Complications of Pheochromocytomas and Paragangliomas

“…Catecholamine myocarditis as a complication of PPGLs has been reported since decades [71,72]. The diagnosis of PPGL-induced myocarditis was based on the clinical picture, ECG changes [73], histopathological features through either endomyocardial biopsy [74] or autopsy [71], and cardiac magnetic resonance imaging (C-MRI) [61]. In 1966, Van Vliet et al reported that 15 (58%) of 26 patients who died due to pheochromocytoma disclosed disseminated focal myocardial lesion which the authors designated "active catecholamine myocarditis" [71].…”

“…These changes cannot be explained by the effects of hypertension. Cases with clear findings consistent with PPGL-induced TS have been published with the diagnosis myocarditis (Table 1) [58,61]. Based on patchy late gadolinium enhancement on C-MRI, some cases were deemed as PPGL-induced myocarditis [61].…”

“…Cases with clear findings consistent with PPGL-induced TS have been published with the diagnosis myocarditis (Table 1) [58,61]. Based on patchy late gadolinium enhancement on C-MRI, some cases were deemed as PPGL-induced myocarditis [61]. Worth mentioning, C-MRI may show patchy late gadolinium enhancement in one third of patients with TS [80].…”

“…Second, many cases with features and course typical for PPGL-induced TS, specially before recognition of the term takotsubo, have been published under various cardiac diagnoses [27] as recurrent myocardial infarction with left ventricular aneurysm complicated by left ventricular thrombus [50], "transient shock and myocardial impairment caused by pheochromocytoma crisis" [54], reversible catecholamine-induced cardiomyopathy [57,104], myocardial stunning-like phenomenon during a PPGL-crisis [105], myocarditis diagnosed by C-MRI [61] and so on (Table 1) [51,52,55,56,[58][59][60]. Batisse-Lignier et al reviewed systematically 145 published cases of pheochromocytoma-induced "acute and chronic cardiomyopathy" [106].…”

Autonomic neurocardiogenic syndrome is stonewalled by the universal definition of myocardial infarction

“…CMR imaging, if done early during TS, may reveal LGE in the affected hypokinetic segments in about one third of cases[ 33 ]. However, the signal intensity of LGE in TS is less than that of MI and myocarditis and the LGE is patchy in appearance and in some cases described as myocarditis[ 34 , 35 ]; chemical (neuro-mediated by norepinephrine) myocarditis may be a feature of TS[ 36 ] and may explain the patchy LGE findings in TS; it is usually reversible (neurogenic stunning). Moreover, the most important sign, which challenges MI in TS, is the histo-pathological finding of contraction band necrosis, which is distinct from coagulation necrosis seen in MI[ 37 ].…”