Pheochromocytoma Presenting As Acute Myocardial Infarction

Abstract

Pheochromocytomas are rare neuro-endocrine tumors arising from chromaffin cells of the sympathetic nervous system.Pheochromocytomacan have diverse clinical presentations, which makes the diagnosis often difficult. We present a case of adrenalpheochromocytoma presenting as acute ST elevation myocardial infarction (STEMI). Catecholamine surge in patients with pheochromocytoma can cause myocardial infarction in the absence of atherosclerotic coronary artery disease. Pheochromocytoma presenting as acute myocardial infarction is very rare and it occurs in young individuals. This is a rare case report of pheochromocytoma in an elderly male presenting with acute STEMI successfully treated by resection of tumor.Key words: pheochromocytoma, myocardial infarction, catecholamines, hypertension Case ReportA 62 year old farmer presented with severe epigastric discomfort, vomiting and profuse sweating. He was hypertensive and diabetic since last four years poorly compliant on treatment. His blood pressure was 190/110 mmHg and heart rate was 60 beats per minute. Precordial examination was unremarkable except for a loud fourth heart sound. Initial ECG showed tall peaked T waves in precordial leads suggesting hyperacute changes of myocardial infarction. Subsequent ECGs showed loss of R waves with coved ST elevation and T wave inversion in leads V2,V3 and V4. Leads I,II,III,aVF, V5 and V6 showed T wave inversions (Fig 1). His echocardiogram showed severe hypokinesia of apical interventricular septum and apex with normal left ventricular systolic function.He was subjected to an immediate coronary angiogram with intention for primary percutaneous revascularization. Surprisingly his diagnostic coronary angiogram showed normal epicardial coronary arteries and no evidence of atherosclerosis (Fig 2).So he was treated conservatively with antiplatelet agents, nitroglycerine and statins.In his subsequent ECG sprecordial ST segment returned to baseline with deep T wave inversions, typical of serial evolutionary changes of STEMI. Cardiac enzymes were elevated, serum troponin I of 9ng/ml, (normal cut off is less than 0.05ng/ml).During the hospital stay he developed recurrent episodes of similar but less intense episodes of abdominal discomfort and vomiting. His blood pressure increased to levels as high as 200/120 mm of Hg during the episodes along with sinus tachycardia. This prompted us to suspect an alternative diagnosis in this case. His thyroid function tests were normal. In view of the labile hypertensive changes, we also considered the possibility of pheochromocytoma and proceed with an ultra sonogram of the abdomen which showed a mass in the region of right suprarenal gland. 24 hr urine metanephrine levels were elevated (14.5 mg, normal value < 1 mg/24 hrs). A contrast enhanced CT scan of abdomen showed right suprarenal mass which was a well encapsulated with a fluid level (Fig 3). Both kidneys and left suprarenal gland were normal. Thus we arrived at a diagnosis of pheochromocytoma and the acute myocardial infarction was pr...

Catecholamine-Induced Cardiomyopathy in Pheochromocytoma: How to Manage a Rare Complication in a Rare Disease?

“…The ECG revealed ST depression in the anterior and inferior aspects, elevated troponin T, and echocardiogram showed severe hypokinesis of anterior septal, basal, inferior, and posterior segments with normal systolic function [48]. On the other hand, due to high levels of catecholamines, even without myocardial ischemia or infarction, patients can present with inverted T waves, hyperacute T waves, ST elevation, abnormal R wave progression, and diffused low voltage [65]. In a study done by Schurmeyer et al including 106 patients, endocrine and cardiologic findings in 106 patients with PHEO were assessed.…”

“…Some ECG findings that may be found in catecholamine-secreting PHEO patients include right axis deviation, generalized low voltage [79], ventricular hypertrophy [80], abnormal R wave progression, abnormally peaked P waves, low amplitude or inverted T waves, elevation of ST segment, T wave changes, prolonged corrected QT interval, sick sinus syndrome, supraventricular and ventricular tachycardia, torsades de pointe, and ventricular fibrillation [65,[81][82][83][84].…”