1
|
Istratoaie S, Kovacs E, Manole S, Inceu AI, Axente DD, Bungărdean RM, Șerban AM. A Late-Detected Paraganglioma in a Young Patient with Resistant Hypertension and Severe Aortic Regurgitation-A Case Report and Review of the Literature. J Clin Med 2023; 12:4694. [PMID: 37510808 PMCID: PMC10380848 DOI: 10.3390/jcm12144694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 07/02/2023] [Accepted: 07/12/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Paraganglioma is a rare neuroendocrine tumor derived from chromaffin cells. The overproduction of catecholamines accounts for the presenting symptoms and cardiovascular complications. The clinical presentation frequently overlaps with the associated cardiac diseases, delaying the diagnosis. Multimodality imaging and a multidisciplinary team are essential for the correct diagnosis and adequate clinical management. CASE SUMMARY A 37-year-old woman with a personal medical history of long-standing arterial hypertension and radiofrequency ablation for atrioventricular nodal reentry tachycardia presented with progressive exertional dyspnea and elevated blood pressure values, despite a comprehensive pharmacological treatment with six antihypertensive drugs. The echocardiography showed a bicuspid aortic valve and severe aortic regurgitation. The computed tomography angiography revealed a retroperitoneal space-occupying solid lesion, with imaging characteristics suggestive of a paraganglioma. The multidisciplinary team concluded that tumor resection should be completed first, followed by an aortic valve replacement if necessary. The postoperative histopathology examination confirmed the diagnosis of paraganglioma. After the successful resection of the tumor, the patient was asymptomatic, and the intervention for aortic valve replacement was delayed. DISCUSSION This was a rare case of a late-detected paraganglioma in a young patient with resistant hypertension overlapping the clinical presentation and management of severe aortic regurgitation. A multimodality imaging approach including transthoracic and transesophageal echocardiography, computed tomography, and magnetic resonance imaging had an emerging role in establishing the diagnosis and in guiding patient management and follow-up. The resection of paraganglioma was essential for the optimal timing of surgical correction for severe aortic regurgitation. We further reviewed various cardiovascular complications induced by pheochromocytomas and paragangliomas.
Collapse
Affiliation(s)
- Sabina Istratoaie
- Department of Pharmacology, Toxicology, and Clinical Pharmacology, "Iuliu Haţieganu" University of Medicine and Pharmacy, 400337 Cluj-Napoca, Romania
- Department of Cardiology, "Niculae Stăncioiu" Heart Institute, 400001 Cluj-Napoca, Romania
| | - Emese Kovacs
- Department of Cardiology, "Niculae Stăncioiu" Heart Institute, 400001 Cluj-Napoca, Romania
| | - Simona Manole
- Department of Radiology, "Niculae Stăncioiu" Heart Institute, 400001 Cluj-Napoca, Romania
- Department of Radiology, "Iuliu Hatieganu" University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Andreea Ioana Inceu
- Department of Pharmacology, Toxicology, and Clinical Pharmacology, "Iuliu Haţieganu" University of Medicine and Pharmacy, 400337 Cluj-Napoca, Romania
- Department of Cardiology, "Niculae Stăncioiu" Heart Institute, 400001 Cluj-Napoca, Romania
| | - Dan Damian Axente
- Cluj-Napoca Municipal Clinical Hospital, 400139 Cluj-Napoca, Romania
| | - Raluca Maria Bungărdean
- Department of Pathology, "Iuliu Hatieganu" University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Adela Mihaela Șerban
- Department of Cardiology, "Niculae Stăncioiu" Heart Institute, 400001 Cluj-Napoca, Romania
- 5th Department of Internal Medicine, "Iuliu Haţieganu" University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| |
Collapse
|
2
|
Mayuga KA, Fedorowski A, Ricci F, Gopinathannair R, Dukes JW, Gibbons C, Hanna P, Sorajja D, Chung M, Benditt D, Sheldon R, Ayache MB, AbouAssi H, Shivkumar K, Grubb BP, Hamdan MH, Stavrakis S, Singh T, Goldberger JJ, Muldowney JAS, Belham M, Kem DC, Akin C, Bruce BK, Zahka NE, Fu Q, Van Iterson EH, Raj SR, Fouad-Tarazi F, Goldstein DS, Stewart J, Olshansky B. Sinus Tachycardia: a Multidisciplinary Expert Focused Review. Circ Arrhythm Electrophysiol 2022; 15:e007960. [PMID: 36074973 PMCID: PMC9523592 DOI: 10.1161/circep.121.007960] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Sinus tachycardia (ST) is ubiquitous, but its presence outside of normal physiological triggers in otherwise healthy individuals remains a commonly encountered phenomenon in medical practice. In many cases, ST can be readily explained by a current medical condition that precipitates an increase in the sinus rate, but ST at rest without physiological triggers may also represent a spectrum of normal. In other cases, ST may not have an easily explainable cause but may represent serious underlying pathology and can be associated with intolerable symptoms. The classification of ST, consideration of possible etiologies, as well as the decisions of when and how to intervene can be difficult. ST can be classified as secondary to a specific, usually treatable, medical condition (eg, pulmonary embolism, anemia, infection, or hyperthyroidism) or be related to several incompletely defined conditions (eg, inappropriate ST, postural tachycardia syndrome, mast cell disorder, or post-COVID syndrome). While cardiologists and cardiac electrophysiologists often evaluate patients with symptoms associated with persistent or paroxysmal ST, an optimal approach remains uncertain. Due to the many possible conditions associated with ST, and an overlap in medical specialists who see these patients, the inclusion of experts in different fields is essential for a more comprehensive understanding. This article is unique in that it was composed by international experts in Neurology, Psychology, Autonomic Medicine, Allergy and Immunology, Exercise Physiology, Pulmonology and Critical Care Medicine, Endocrinology, Cardiology, and Cardiac Electrophysiology in the hope that it will facilitate a more complete understanding and thereby result in the better care of patients with ST.
Collapse
Affiliation(s)
- Kenneth A. Mayuga
- Section of Cardiac Electrophysiology and Pacing, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | - Artur Fedorowski
- Karolinska Institutet & Karolinska University Hospital, Stockholm, Sweden
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, “G.d’Annunzio” University of Chieti-Pescara, Chieti Scalo, Italy
| | | | | | | | | | | | - Mina Chung
- Section of Cardiac Electrophysiology and Pacing, Department of Cardiovascular Medicine, Cleveland Clinic, Phoenix, AZ
| | - David Benditt
- University of Minnesota Medical School, Minneapolis, MN
| | | | - Mirna B. Ayache
- MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Hiba AbouAssi
- Division of Endocrinology, Metabolism, and Nutrition, Duke University Medical Center, Durham, NC
| | | | | | | | | | - Tamanna Singh
- Department of Cardiovascular Medicine, Cleveland Clinic, OH
| | | | - James A. S. Muldowney
- Vanderbilt University Medical Center &Tennessee Valley Healthcare System, Nashville Campus, Department of Veterans Affairs, Nashville, TN
| | - Mark Belham
- Cambridge University Hospitals NHS FT, Cambridge, UK
| | - David C. Kem
- University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Cem Akin
- University of Michigan, Ann Arbor, MI
| | | | - Nicole E. Zahka
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Qi Fu
- Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Hospital Dallas & University of Texas Southwestern Medical Center, Dallas, TX
| | - Erik H. Van Iterson
- Section of Preventive Cardiology & Rehabilitation, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic Cleveland, OH
| | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | | | | | | | | |
Collapse
|
3
|
Recurrent Stress Cardiomyopathy: A Rare Variant in a Young Patient with Undiagnosed Pheochromocytoma. Case Rep Cardiol 2021; 2021:5518578. [PMID: 34188960 PMCID: PMC8195023 DOI: 10.1155/2021/5518578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 04/14/2021] [Accepted: 04/20/2021] [Indexed: 11/24/2022] Open
Abstract
Biventricular stress cardiomyopathy is one of several known anatomical variants of reversible cardiomyopathies to occur. We present a case of a young patient with recurrent stress cardiomyopathy complicated by cardiogenic shock in the perioperative period. The cardiomyopathy observed was in a patient with neurofibromatosis type I and undiagnosed pheochromocytoma who presented for intervention of hydrocephalus. This case demonstrates the importance of vigilance in the young patient who develops shock in the perioperative period.
Collapse
|
4
|
High prevalence of cardiac electric abnormalities in patients with phaeochromocytomas. J Hypertens 2018; 35:899-901. [PMID: 28248910 DOI: 10.1097/hjh.0000000000001236] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
|
5
|
Suzuki K, Miyake T, Okada H, Yamaji F, Kitagawa Y, Fukuta T, Yasuda R, Tanaka Y, Okamoto H, Nachi S, Doi T, Yoshida T, Kumada K, Yoshida S, Ushikoshi H, Toyoda I, Ogura S. Thyrotoxic and pheochromocytoma multisystem crisis: a case report. J Med Case Rep 2017. [PMID: 28641581 PMCID: PMC5481964 DOI: 10.1186/s13256-017-1299-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Background Thyrotoxic crisis and pheochromocytoma multisystem crisis are rare, life-threatening, emergency endocrine diseases with various clinical manifestations. Here we report a case of a patient who simultaneously developed thyrotoxic crisis and pheochromocytoma multisystem crisis and required intensive cardiovascular management. Case presentation A 60-year-old Asian man experienced nausea and vomiting, and subsequently developed dyspnea and cold sweats while farming. His serum free thyroxine, free triiodothyronine, and thyrotropin receptor antibody levels were elevated at 2.9 ng/dL, 7.2 pg/dL, and 4.7 IU/L, respectively. Serum thyrotropin levels were suppressed at less than 0.01 μIU/mL. Thyroid echography demonstrated no thyroid swelling (23 × 43 mm). A whole body computed tomography was performed for systemic evaluation. This revealed exophthalmos and a mass of size 57 × 64 mm in the anterior pararenal space. Based on these findings, we made an initial diagnosis of thyrotoxic crisis secondary to exacerbation of Grave’s hyperthyroidism. Treatment was begun with an iodine agent at a dose of 36 mg/day, thiamazole at a dose of 30 mg/day, and hydrocortisone at a dose of 300 mg daily for 3 consecutive days. To control tachycardia, continuous intravenously administered propranolol and diltiazem infusions were given. At the same time, small doses of doxazosin and carvedilol were used for both alpha and beta adrenergic blockade. On hospital day 5, his blood pressure and serum catecholamine concentrations (adrenalin 42,365 pg/mL, dopamine 6409 pg/mL, noradrenalin 72,212 pg/mL) were still high despite higher beta blocker and calcium channel blocker doses. These findings contributed to the diagnosis of pheochromocytoma multisystem crisis with simultaneous thyrotoxic crisis. We increased the doses of doxazosin and carvedilol, which stabilized his hemodynamic status. On hospital day 16, metaiodobenzylguanidine scintigraphy showed high accumulation in the right adrenal gland tumor. After retroperitoneal laparoscopic adrenalectomy on hospital day 33, his condition stabilized. He was discharged on hospital day 58. Conclusions Since he required more intensive cardiovascular management for thyrotoxic crisis, beta blockade was increased under intensive care unit monitoring even though initial alpha blockade is recommended in pheochromocytoma. When these crises occur simultaneously, cardiovascular management can be very challenging.
Collapse
Affiliation(s)
- Kodai Suzuki
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Takahito Miyake
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Hideshi Okada
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan.
| | - Fuminori Yamaji
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Yuichiro Kitagawa
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Tetsuya Fukuta
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Ryu Yasuda
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Yoshihito Tanaka
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Haruka Okamoto
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Sho Nachi
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Tomoaki Doi
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Takahiro Yoshida
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Keisuke Kumada
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Shozo Yoshida
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Hiroaki Ushikoshi
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Izumi Toyoda
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Shinji Ogura
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| |
Collapse
|
6
|
Hekimian G, Kharcha F, Bréchot N, Schmidt M, Ghander C, Lebreton G, Girerd X, Tresallet C, Trouillet JL, Leprince P, Chastre J, Combes A, Luyt CE. Extracorporeal membrane oxygenation for pheochromocytoma-induced cardiogenic shock. Ann Intensive Care 2016; 6:117. [PMID: 27896787 PMCID: PMC5126035 DOI: 10.1186/s13613-016-0219-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 11/21/2016] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Pheochromocytoma, a rare catecholamine-producing tumor, might provoke stress-induced Takotsubo-like cardiomyopathy and severe cardiogenic shock. Because venoarterial-extracorporeal membrane oxygenation (VA-ECMO) rescue of pheochromocytoma-induced refractory cardiogenic shock has rarely been reported, we reviewed our ICU patients' presentations and outcomes. METHODS All pheochromocytoma-induced refractory cardiogenic shock cases managed with VA-ECMO (January 2007-March 2015) were prospectively included and reviewed. We also performed a systematic review on this topic. RESULTS Nine patients (7 women, 2 men; 31-51 [median, 43 (IQR 36-49) years old]) were included; none had a previously known pheochromocytoma. Six of them had medical histories suggestive of the diagnosis: palpitations and headaches for several months for four, multiple endocrine neoplasia syndrome type 1 for one and recurrent Takotsubo disease for one; at hospital admission, all were hypertensive despite cardiogenic shock. Three others had an identified surgical triggering factor. All nine patients rapidly developed refractory cardiogenic shock with very severe left ventricular (LV) impairment (LV ejection-fraction range 5-20%; LV outflow-tract velocity-time integral range 3-8 cm). Seven patients' abdominal computed tomography scans showed pheochromocytoma-suggestive adrenal gland tumors (no scan during ICU stay for 2). Despite VA-ECMO implantation, three patients died of refractory multiple organ failure. For the six others, myocardial function improved and ECMO was removed 3-7 days post-implantation; α- and β-blockers were progressively introduced. Five survivors underwent pheochromocytoma excision 3 weeks-4 months post-ICU discharge, with satisfactory outcomes. One patient, whose pheochromocytoma was diagnosed 1 year after the index event, underwent uneventful surgical adrenalectomy. Systematic review retrieved 40 cases of pheochromocytoma-induced cardiogenic shock requiring mechanical support (mostly ECMO), with a mortality rate of 7%. Pheochromocytoma was removed surgically after mechanical support weaning in 31 patients and during mechanical support in 5. Four were not operated. CONCLUSIONS Pheochromocytoma is a rare but reversible cause of cardiogenic shock amenable to VA-ECMO rescue. Adrenal gland imaging should be obtained for all patients with unexplained cardiogenic shock. Lastly, it might be safer to perform adrenalectomy several weeks after the initial catastrophic presentation, once recovery of LV systolic function is complete.
Collapse
Affiliation(s)
- Guillaume Hekimian
- Intensive Care Unit, Institute of Cardiology, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France. .,UPMC Université Paris 06, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France.
| | - Fatima Kharcha
- Institute of Endocrinology, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Nicolas Bréchot
- Intensive Care Unit, Institute of Cardiology, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.,UPMC Université Paris 06, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Matthieu Schmidt
- Intensive Care Unit, Institute of Cardiology, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.,UPMC Université Paris 06, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Cécile Ghander
- Institute of Endocrinology, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Guillaume Lebreton
- Department of Cardiac and Thoracic Surgery, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Xavier Girerd
- Institute of Endocrinology, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Christophe Tresallet
- Department of General and Endocrine Surgery, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Jean-Louis Trouillet
- Intensive Care Unit, Institute of Cardiology, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.,UPMC Université Paris 06, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Pascal Leprince
- Department of Cardiac and Thoracic Surgery, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Jean Chastre
- Intensive Care Unit, Institute of Cardiology, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.,UPMC Université Paris 06, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Alain Combes
- Intensive Care Unit, Institute of Cardiology, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.,UPMC Université Paris 06, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Charles-Edouard Luyt
- Intensive Care Unit, Institute of Cardiology, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.,UPMC Université Paris 06, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| |
Collapse
|
7
|
Endomyocardial Biopsy in acute cardiogenic shock: Diagnosis of pheochromocytoma. Int J Cardiol 2015; 202:897-9. [PMID: 26479955 DOI: 10.1016/j.ijcard.2015.10.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 10/04/2015] [Indexed: 11/22/2022]
|