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Xie Y, Zhang A, Qi M, Xiong B, Zhang S, Zhou J, Cao Y. Pheochromocytoma crisis with refractory Acute Respiratory Distress Syndrome (ARDS), Takotsubo syndrome, emergency adrenalectomy, and need for Extracorporeal Membrane Oxygenation (ECMO) in a previously undiagnosed and asymptomatic patient, due to the use of metoclopramide. BMC Endocr Disord 2023; 23:145. [PMID: 37430225 PMCID: PMC10332044 DOI: 10.1186/s12902-023-01404-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 07/04/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Pheochromocytoma (PCC) crisis is a rare life-threatening endocrine emergency. The diagnosis and treatment of PCC crisis, with acute respiratory distress syndrome (ARDS) as the first manifestation, is highly challenging, and traditional PCC management strategies are no longer suitable for these patients. CASE PRESENTATION A 46-year-old female patient was admitted to the Intensive Care Unit (ICU) following sudden-onset acute respiratory distress and subsequent initiation of mechanical ventilation via endotracheal intubation. She was initially suspected of having a PCC crisis through the bedside critical care ultrasonic examination protocol. The computed tomography examination revealed a left adrenal neoplasm of 6.5cm × 5.9cm. The plasma-free metanephrine level was 100 times higher than the reference value. These findings were compatible with her PCC diagnosis. Alpha-blockers and fluid intake were started immediately. The endotracheal intubation was removed on the 11th day after admission to the ICU. The patient progressed to severe ARDS again, and invasive ventilation and continuous renal replacement therapy were needed. Despite aggressive therapy, her condition deteriorated. Therefore, she underwent veno-arterial extracorporeal membrane oxygenation (VA-ECMO)-assisted emergency adrenalectomy after multidisciplinary discussion. Postoperatively, the patient was supported by VA-ECMO for 7days. She was discharged from the hospital on day 30 after tumor resection. CONCLUSIONS This case highlighted the challenges in diagnosing and managing ARDS associated with PCC crisis. The traditional preoperative preparation protocol and optimal operation timing for patients with PCC are not suitable for patients with PCC crisis. Patients with life-threatening PCC crisis may benefit from early tumor removal, and VA-ECMO could maintain hemodynamic stability during and after surgery.
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Affiliation(s)
- Yuhua Xie
- Department of Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - An Zhang
- Department of Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Min Qi
- Department of Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Bin Xiong
- Department of Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Suhua Zhang
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jianzhong Zhou
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yunxing Cao
- Department of Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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Muacevic A, Adler JR, Rajkanna J. Acute Pulmonary Edema as a Cardiovascular Manifestation of Pheochromocytoma. Cureus 2023; 15:e33675. [PMID: 36788877 PMCID: PMC9918853 DOI: 10.7759/cureus.33675] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2023] [Indexed: 01/15/2023] Open
Abstract
Pheochromocytoma most commonly presents with the triad of paroxysms of headache, palpitations, and diaphoresis. Pheochromocytoma crisis, caused by a supra-physiological surge of catecholamine release, is an endocrine emergency that can present with various clinical manifestations. Acute pulmonary edema is one of the manifestations of pheochromocytoma crisis and can be either cardiogenic or non-cardiogenic. Here, we report cases of acute pulmonary edema of each type, related to pheochromocytoma crisis, which were presented to our district general hospital in 2020.
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Liu Y, Wang N, Li S, Jiang L, Liu C, Xu J, He H. Pheochromocytoma with Acute Non-cardiac Pulmonary Edema: A Report of One Case and the Review of Literature. Cancer Invest 2021; 39:908-913. [PMID: 34569904 DOI: 10.1080/07357907.2021.1986837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The present study reports the clinical data of a patient with pheochromocytoma who developed acute non-cardiac pulmonary edema. The patient has already been followed for 2 years after the initial surgery. Based on the case of our patient, and after the review of existing literature, we find that cases of patients who present dyspnea, shock and the lung changes of interstitial without according to respiratory common diseases tend to perform abdominal computed tomography (CT) to exclude pheochromocytoma. In addition, after receiving symptomatic treatment in acute left heart failure and pulmonary edema patients, having the poor effect, we have to consider the diagnosis of pheochromocytoma.
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Affiliation(s)
- Yuan Liu
- Department of Pneumology, Dalian Municipal Central Hospital, Dalian, China
| | - Ning Wang
- Department of Medical Examination Center, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shi Li
- Department of Pneumology, Dalian Municipal Central Hospital, Dalian, China
| | - Ling Jiang
- Department of Pneumology, Dalian Municipal Central Hospital, Dalian, China
| | - Chunfang Liu
- Department of Pneumology, Dalian Municipal Central Hospital, Dalian, China
| | - Jian Xu
- Department of Pneumology, Dalian Municipal Central Hospital, Dalian, China
| | - Huadong He
- Department of Urology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Yeoh CJ, Ng SY, Goh BKP. Pheochromocytoma Multisystem Crisis Triggered by Glucocorticoid Administration and Aggravated by Citrate Dialysis. ACTA ACUST UNITED AC 2017; 8:58-60. [PMID: 27828782 DOI: 10.1213/xaa.0000000000000423] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Pheochromocytoma multisystem crisis is the most severe presentation of pheochromocytoma. We report on a 68-year-old survivor of pheochromocytoma multisystem crisis, whose clinical course was triggered inadvertently by a short innocuous course of oral dexamethasone to suppress inflammation and swelling after a left orbital floor fracture repair. He presented first with severe epigastric pain and headache, and subsequently experienced insults to neurological, cardiac, respiratory, hepatobiliary, renal, and immune system in his prolonged intensive care unit stay. We believe an episode of unexpected hypertensive crisis in the intensive care unit was set off iatrogenically during citrate protocol dialysis.
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Affiliation(s)
- Chuen Jye Yeoh
- From the Departments of *Anaesthesiology and †Hepato-Pancreato-Biliary and Transplant Surgery, Singapore General Hospital, Singapore
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Abstract
Three pools of exhaled breath condensate (EBC) from non-smokers plus healthy smokers (NS + HS, n = 45); chronic obstructive pulmonary disease (COPD) without emphysema (COPD, n = 15) and subjects with pulmonary emphysema associated with α1-antitrypsin deficiency (AATD, n = 23) were used for an exploratory proteomic study aimed at generating fingerprints of these groups that can be used in future pathophysiological and perhaps even clinical research. Liquid chromatography-tandem mass spectrometry (LC-MS/MS) was the platform applied for this hypothesis-free investigation. Analysis of pooled specimens resulted in the production of a “fingerprint” made of 44 proteins for NS/HS; 17 for COPD and 15 for the group of AATD subjects. Several inflammatory cytokines (IL-1α, IL-1β, IL-2; IL-12, α and β subunits, IL-15, interferon α and γ, tumor necrosis factor α); Type I and II cytokeratins; two SP-A isoforms; Calgranulin A and B and α1-antitrypsin were detected and validated through the use of surface enhanced laser-desorption ionization mass spectrometry (SELDI-MS) and/or by Western blot (WB) analysis. These results are the prelude of quantitative studies aimed at identifying which of these proteins hold promise as identifiers of differences that could distinguish healthy subjects from patients.
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Abstract
Clinical expression of phaeochromocytoma may involve numerous cardiovascular manifestations, but usually presents as sustained or paroxysmal hypertension associated with other signs and symptoms of catecholamine excess. Most of the life-threatening cardiovascular manifestations of phaeochromocytoma, such as hypertensive emergencies, result from a rapid and massive release of catecholamines from the tumour. More rarely, patients with phaeochromocytoma present with low blood pressure or even shock that may then precede multisystem crisis. Sinus tachycardia, with palpitations as the presenting symptom, is the most prevalent abnormality of cardiac rhythm in phaeochromocytoma, but tumours can also be associated with more serious ventricular arrhythmias or conduction disturbances. Reversible dilated or hypertrophic cardiomyopathy are well established cardiac manifestations of phaeochromocytoma, with more recent attention to an increasing number of cases with Takotsubo cardiomyopathy. This review provides an update on the cause, clinical presentation and treatment of the cardiovascular manifestations of phaeochromocytoma. As the cardiovascular complications of phaeochromocytoma can be life-threatening, all patients who present with manifestations that even remotely suggest excessive catecholamine secretion should be screened for the disease.
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Rassler B. Contribution of α - and β -Adrenergic Mechanisms to the Development of Pulmonary Edema. SCIENTIFICA 2012; 2012:829504. [PMID: 24278744 PMCID: PMC3820440 DOI: 10.6064/2012/829504] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Accepted: 07/18/2012] [Indexed: 05/04/2023]
Abstract
Endogenous or exogenous catecholamines can induce pulmonary edema (PE). This may occur in human pathologic conditions such as in pheochromocytoma or in neurogenic pulmonary edema (NPE) but can also be provoked after experimental administration of adrenergic agonists. PE can result from stimulation with different types of adrenergic stimulation. With α-adrenergic treatment, it develops more rapidly, is more severe with abundant protein-rich fluid in the alveolar space, and is accompanied by strong generalized inflammation in the lung. Similar detrimental effects of α-adrenergic stimulation have repeatedly been described and are considered to play a pivotal role in NPE or in PE in patients with pheochromocytoma. Although β-adrenergic agonists have often been reported to prevent or attenuate PE by enhancing alveolar fluid clearance, PE may also be induced by β-adrenergic treatment as can be observed in tocolysis. In experimental models, infusion of β-adrenergic agonists induces less severe PE than α-adrenergic stimulation. The present paper addresses the current understanding of the possible contribution of α- and β-adrenergic pathways to the development of PE.
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Affiliation(s)
- Beate Rassler
- Carl Ludwig Institute of Physiology, University of Leipzig, Liebigstraße 27, 04103 Leipzig, Germany
- *Beate Rassler:
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Takotsubo-like cardiomyopathy in pheochromocytoma. Int J Cardiol 2011; 153:241-8. [PMID: 21474192 DOI: 10.1016/j.ijcard.2011.03.027] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Revised: 03/03/2011] [Accepted: 03/11/2011] [Indexed: 12/15/2022]
Abstract
BACKGROUND Takotsubo Cardiomyopathy (TTC) is commonly triggered by acute illness, physical or emotional stress and has been associated with elevated catecholamine levels. TTC has also been associated with pheochromocytoma (TTC-pheo). METHODS We performed a computer assisted search of the electronic databases Medline, Scopus and Google Scholar from 1965 to January 2011. All case reports with reported TTC-pheo were selected and compared to a recent review by Gianni et al. which examined primary TTC (TTC-primary). STATISTICS Data analysis was performed using SPSS version 18. Chi-square test of Fisher's exact test was used as appropriate to compare categorical data. RESULTS 38 cases of TTC-pheo were retrieved from literature and compared to 254 cases of TTC-p. Chest pain was the most common presentation in both groups. The TTC-pheo patients were on average 18 years younger than patients with TTC-p (p<0.01). Only a minority of TTC-pheo patients presented with classical features of pheochromocytoma including hypertension (52.6%), headache (28.9%), palpitations (31.6 %), and diaphoresis (26.3%). In TTC-pheo complications rates were higher compared to TTC-p, including cardiogenic shock (34.2% vs. 4.2%, p<0.01) and heart failure (46.7% vs. 17.7%, p<0.01). Antecedent stressors were less common in TTC-pheo. About one-third of TTC-pheo patients presented with the inverted pattern, which compared to the apical pattern, was associated with higher complication rates, including, cardiogenic shock, heart failure, acute renal failure and arrhythmias. CONCLUSIONS Although rare, pheochromocytoma should be considered in the differential diagnosis of TTC especially in younger patients presenting without antecedent stressors and a high complication rate. The similarities in the clinical features and outcomes in patients with TTC-p and TTC-pheo point to a similar underlying cardiac pathophysiologic process at the time of the acute presentation.
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Uchida N, Ishiguro K, Suda T, Nishimura M. Pheochromocytoma multisystem crisis successfully treated by emergency surgery: Report of a case. Surg Today 2010; 40:990-6. [DOI: 10.1007/s00595-009-4165-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2009] [Accepted: 08/31/2009] [Indexed: 11/28/2022]
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Kim CK, Han SJ, Lee JH, Kwon YE. Acute Pulmonary Edema for Surgical Removal of Pheochromocytoma - A case report -. Korean J Anesthesiol 2007. [DOI: 10.4097/kjae.2007.53.3.411] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Cheol Kun Kim
- Department of Anesthesiology and Pain Medicine, Presbyterian Medical Center, Jeonju, Korea
| | - Sang Ji Han
- Department of Anesthesiology and Pain Medicine, Presbyterian Medical Center, Jeonju, Korea
| | - Jun Hak Lee
- Department of Anesthesiology and Pain Medicine, Presbyterian Medical Center, Jeonju, Korea
| | - Young Eun Kwon
- Department of Anesthesiology and Pain Medicine, Presbyterian Medical Center, Jeonju, Korea
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Brouwers FM, Eisenhofer G, Lenders JWM, Pacak K. Emergencies caused by pheochromocytoma, neuroblastoma, or ganglioneuroma. Endocrinol Metab Clin North Am 2006; 35:699-724, viii. [PMID: 17127142 DOI: 10.1016/j.ecl.2006.09.014] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Pheochromocytoma may lead to important emergency situations, ranging from cardiovascular emergencies to acute abdomen and multiorgan failure. It is vital to think about this disease in any emergency situation when conventional therapy fails to achieve control or symptoms occur that do not fit the initial diagnosis. The importance of keeping this diagnosis in minds is underscored by the fact that, in 50% of pheochromocytoma patients, the diagnosis is initially overlooked. Two other tumors of the sympathetic nervous system, neuroblastoma and ganglioneuroma, are less commonly associated with emergency conditions. If they occur, they are often linked to catecholamine excess, paraneoplastic phenomena, or local tumor mass effect.
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Affiliation(s)
- Frederieke M Brouwers
- Section on Medical Neuroendocrinology, Reproductive Biology and Medicine Branch, National Institute of Child Health and Human Development, Bethesda, MD 20892-1109, USA
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