Case Report

Ruptured pheochromocytoma presents as acute myocardial infarction

Abstract

Pheochromocytomas are uncommon catecholamine-se- creting tumors. The most common symptoms are of paroxysmal or sustained hypertension, or symptoms of paroxysmal adrenergic stimulation as palpitation, headache, and diaphoresis. The diversity of presentation often delays the diagnosis and is sometimes with Catastrophic outcome. It had not been reported that acute myocardial infarction is a complication of ruptured pheochromocytoma. We describe a case with emergency department presented as acute myocardial infarction initially. On the following day, sudden drop of blood pressure and syncope attacked him. Coronary angiography revealed noncritical obstruction on proximal left anterior descending artery. After angioplasty, the patient still experienced episodes of Hemodynamic collapse, and left flank pain developed. Abdominal computer tomogram demonstrated a large left adrenal tumor with fluid accumula- tion. Finally, the patient underwent surgical treatment and pathology confirmed the diagnosis.

A 63-year-old man presented with Chest tightness and palpitation. He did not have any medical history of hypertension and was asymptomatic before. His Blood pressure was 191/114 mm Hg and pulse rate was 104 beats/min on arrival. Physical examination did not reveal any abnormalities. His electrocardiogram (ECG) demonstrated a 2-mm ST-segment depression in the precordial leads. The chest x-ray film was normal. Biochemical analysis demon- strated elevation levels of troponin I (8.14 ug/L; reference range, 0-0.04 ug/L), with abnormal levels of total creatine kinase (CK, 617 U/L; reference range, 30-170 U/L) and CK- myocardial isoenzyme (CK-MB, 70 U/L; reference range, 0-16 U/L). He was admitted to our intensive care unit under the suspicion of acute myocardial infarction. Treatment with antihypertension agents, anticoagulants, and nitrate was initiated. Chest tightness was more relieved after admission, but his BP was not well controlled by medication and he presented with persisted tachycardia. The next day, sudden hemodynamic collapse (BP, 78/48 mm Hg; pulse rate, 120 beats/min) was noted when the patient changed his position,

and then he lost his consciousness. There was absence of further change on repeated ECG and no further elevation of cardiac enzyme. Immediate echocardiography revealed a normally sized heart with a good left ventricular contractility. There was neither regional Wall motion abnormality nor pericardial effusion. The patient’s con- scious level and BP were progressively improved by fluid challenge and dopamine infusion. Catheterization was arranged on the following day. The results demonstrated 50% obstruction on proximal site of left anterior descending artery, and angioplasty was performed. On the fourth day of admission, recurrent hypotension and near syncope attacked the patient again, and dull pain on the left flank region was complained. There were neither further ECG changes nor cardiac enzyme abnormality again. Abdominal computer tomogram was arranged, and it revealed a large soft tissue mass about 6.6 x 7.6 cm at the left adrenal gland region and fluid accumulation at the left pararenal space, with invasion of the left renal hilum and cortex (Fig. 1). The laboratory test with 24-hour urine demonstrated high vanillylmandelic acid level of 26.27 mg per 24 hours (reference range, 1-7.5 mg per 24 hours). The patient was advised to undergo surgical treatment. Then the tumor was removed 1 week later, and surgical and microscopic evaluation confirmed the diagnosis of ruptured pheochromocytoma.

Pheochromocytomas are uncommon catecholamine- secreting tumors. The diversity of presentation often delays the diagnosis and is sometimes with catastrophic outcome. Ventricular or supraventricular arrhythmia, hemodynamic collapse, and abnormal electrocardiographic ST-T-segment changes mimicking myocardial infarction had been docu- mented as rare Cardiovascular manifestations [1-3]. The electrocardiography of myocardial infarction may be due to high levels of circulating adrenaline, and possible mechan- ism may be disproportionate oxygen Supply and demand, or Coronary spasm. Most of such cases of Abnormal ECG findings presented with normal coronary artery and without elevated cardiac enzyme [1,3]. In our case, ST-segment depression with elevation of cardiac enzyme suggested the Initial diagnosis of acute myocardial infarction. However, there was noncritical obstruction by coronary angiography. Was coronary artery the culprit? In addition, pheochromo- cytoma was subsequently ruptured by the stress after

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1018.e6 Case Report

Fig. 1 Enhanced abdominal computer tomogram scan showed a large (6.6 x 7.6 cm) soft tissue tumor at the left adrenal gland region with cystic change and mass effect on the left kidney, pancreas, and spleen. Fluid accumulation at the left pararenal space with invasion of the left renal hilum and cortex, and adrenal cyst rupture or hemorrhage is suspicious. Asterisk (*) indicates left adrenal mass; arrowheads, hematoma.

myocardial infarction. The other possibility was myocardial injury as a complication of ruptured pheochromocytoma. Spontaneous rupture of adrenal pheochromocytoma was rare and had been previously reported. Most of such rare cases presented as hemorrhagic shock [4]. Other clinical features and symptoms such as sudden-onset high BP or flank pain had also been reported [5,6]. The presentations were found in our case. However, it had not been reported that acute myocardial infarction is a complication of ruptured pheochromocytoma. In the case, the further diagnosis was probably spontaneous rupture of pheochro- mocytoma superimposed on noncritical coronary lesions, resulting in acute myocardial injury. Then, anticoagulant deteriorated bleeding status and increased the hematoma accumulation, and the patient presented with flank pain subsequently. This was supported by the manifestations of intractable high BP attack initially and recurrent hypoten- sion without Cardiac damage latterly. Pheochromocytoma is often dangerous when unsuspected. It may present as different cardiovascular manifestations. When initial diag- nosis suggests myocardial infarction, a clinical picture that presents with fluctuating BP, and recurrent sudden hemodynamic collapse, it should remain suspicious, especially if clinical presentations cannot be fully explained by the findings of ECG, laboratory, echocardiography, and coronary angiography.

Hung Yi Chen MD

Department of Cardiology Heping Branch, Taipei City Hospital

Taipei City 100, Taiwan E-mail addresses: [email protected]

[email protected]

doi:10.1016/j.ajem.2008.12.016

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