Initial presentation of pheochromocytoma with Takotsubo cardiomyopathy: a brief review of literature

Takotsubo Endocrinopathy

Takotsubo cardiomyopathy (TCMP) is a cardiac disorder, often seen in post-menopausal women, that resembles an acute coronary syndrome in its clinical presentation. The aetiopathogenesis of TCMP may have an endocrine basis, and hence we believe the term 'takotsubo endocrinopathy' may be more appropriate. In this review, we describe the various endocrine disorders that may lead to TCMP. We also describe the pathogenetic mechanism by which these endocrine disorders may lead to TCMP. Cardiomyopathy associated with pheochromocytoma closely resembles TCMP and we have suggested that it must be ruled out in all patients presenting with TCMP. The role of oestrogen deficiency in the pathogenesis of TCMP is examined in this article. The importance of the involvement of an endocrinologist in the management of TCMP is emphasised.

Congestive heart failure and upper extremity deep vein thrombosis: A rare presentation of a pheochromocytoma

Pheochromocytomas are rare catecholamine-secreting neoplasms, occurring in approximately 0.1–0.5% of the patients with hypertension. Typically, a pheochromocytoma presents with hypertension, a paroxysm of headaches, sweating, and palpitation. However, patients may also present with atypical clinical manifestations on rare occasions. This report presents a case involving a young woman who presented with two rare manifestations of pheochromocytomas: congestive heart failure and right upper extremity deep vein thrombosis (DVT). Her cardiomyopathy was completely resolved by surgical and medical therapy, while DVT was resolved with anticoagulation. Pheochromocytoma should be considered in case of sudden and unexplained cardiac failure and/or DVT. Pheochromocytoma-induced cardiomyopathy can be reversed with medical and/or surgical therapy for pheochromocytomas.

Anesthesia Management for Pediatric Patient With Multiple Endocrine Neoplasia Type 2B: A Case Report

Administering anesthesia to patients with pheochromocytoma may cause an exacerbation of catecholamine secretion from the pheochromocytoma secondary to drug administration, stress, or manipulation of the tumor. We present a pediatric patient with undiagnosed multiple endocrine neoplasia type 2B (pheochromocytoma, thyroid carcinoma, and mucosal neuromas), initially diagnosed and treated for postviral myocarditis and cardiomyopathy, who presented for abdominal magnetic resonance imaging (MRI) under general anesthesia. Untreated cardiomyopathy poses an extra anesthesia mortality risk for patients with pheochromocytoma usually due to myocardial failure, myocardial infarction, or hypertensive hemorrhage into the myocardium or brain.

International Expert Consensus Document on Takotsubo Syndrome (Part I): Clinical Characteristics, Diagnostic Criteria, and Pathophysiology

Takotsubo syndrome (TTS) is a poorly recognized heart disease that was initially regarded as a benign condition. Recently, it has been shown that TTS may be associated with severe clinical complications including death and that its prevalence is probably underestimated. Since current guidelines on TTS are lacking, it appears timely and important to provide an expert consensus statement on TTS. The clinical expert consensus document part I summarizes the current state of knowledge on clinical presentation and characteristics of TTS and agrees on controversies surrounding TTS such as nomenclature, different TTS types, role of coronary artery disease, and etiology. This consensus also proposes new diagnostic criteria based on current knowledge to improve diagnostic accuracy.

International Expert Consensus Document on Takotsubo Syndrome (Part I): Clinical Characteristics, Diagnostic Criteria, and Pathophysiology

Takotsubo syndrome (TTS) is a poorly recognized heart disease that was initially regarded as a benign condition. Recently, it has been shown that TTS may be associated with severe clinical complications including death and that its prevalence is probably underestimated. Since current guidelines on TTS are lacking, it appears timely and important to provide an expert consensus statement on TTS. The clinical expert consensus document part I summarizes the current state of knowledge on clinical presentation and characteristics of TTS and agrees on controversies surrounding TTS such as nomenclature, different TTS types, role of coronary artery disease, and etiology. This consensus also proposes new diagnostic criteria based on current knowledge to improve diagnostic accuracy.

Cardiovascular Manifestations of Pheochromocytoma

Pheochromocytomas are rare endocrine tumors that can have a significant impact on a variety of organ systems, including the cardiovascular system. Although the pathophysiology is not completely understood, pheochromocytomas exert their effects through high levels of catecholamines, mainly epinephrine and norepinephrine, which stimulate adrenergic receptors, including those within the cardiovascular system. Although the most common cardiovascular manifestation is hypertension, patients with pheochromocytoma can present with arrhythmia, hypotension, shock, myocardial ischemia, cardiomyopathy, aortic dissection, and peripheral ischemia. The medical management of the cardiovascular effects of pheochromocytoma is via blockade of adrenergic receptors, usually through the use of alpha blockers, with the addition of beta blockers if needed. However, only surgical resection of the pheochromocytoma is potentially curative, and this tumor requires unique management perioperatively. Because of the variability of presentation and the significant morbidity and mortality of patients with an undiagnosed pheochromocytoma, this entity should not be overlooked in the evaluation of patients with a wide variety of cardiovascular disorders.

Acute systolic heart failure and uncontrolled hypertension: what is the missing link?

Pheochromocytoma is a rare tumor in adults, with an estimated annual incidence of 0.8 per 100,000 persons. Cardiomyopathy is an uncommon presentation of such a rare disease. Serious cardiovascular complications of these tumors are related to potent effects of secreted catecholamines. The mechanism of pheochromocytoma-related cardiomyopathy is not well understood but it is likely due to the effect of excess catecholamines and their oxidation products which have been found to have a direct toxic effect on the myocardium. We describe below a case of a 70-year old female with uncontrolled hypertension and new onset acute systolic heart failure, who on further evaluation was noted to have pheochromocytoma-related cardiomyopathy. Pheochromocytoma should be strongly considered in the differential diagnosis of non-ischemic cardiomyopathy for a patient with elevated blood pressures relative to severity of cardiac dysfunction.

Transient Cardiomyopathy and Quadriplegia Induced by Ephedrine Decongestant

Ephedrine decongestant products are widely used. Common side effects include palpitations, nervousness, and headache. More severe adverse reactions include cardiomyopathy and vasospasm. We report the case of an otherwise healthy 37-year-old woman who presented with acute-onset quadriplegia and heart failure. She had a normal chest radiograph on admission, but developed marked pulmonary edema and bilateral effusions the next day. Echocardiography revealed a left ventricular ejection fraction of 0.18 and no obvious intrinsic pathologic condition such as foramen narrowing on spinal imaging. Laboratory screening was positive for methamphetamines in the urine, and the patient admitted to having used, over the past several weeks, multiple ephedrine-containing products for allergy-symptom relief. She was ultimately diagnosed with an acute catecholamine-induced cardiomyopathy and spinal artery vasospasm consequential to excessive use of decongestants. Her symptoms resolved completely with supportive care and appropriate heart-failure management. An echocardiogram 2 weeks after admission showed improvement of the left ventricular ejection fraction to 0.33. Ten months after the event, the patient was entirely asymptomatic and showed further improvement of her ejection fraction to 0.45. To our knowledge, ours is the first report of spinal artery vasospasm resulting in quadriplegia in a human being after ephedrine ingestion.

MANAGEMENT OF CATECHOLAMINE-SECRETING TUMORS IN PREGNANCY: A REVIEW

OBJECTIVE

Catecholamine-secreting tumors (pheochromocytomas and paragangliomas) presenting during pregnancy are extremely rare, but they can be fatal to both mother and fetus. Recent discoveries in the genetic background of these tumors are expected to address an increasing number of at-risk women to prenatal diagnosis.

METHODS

The literature was reviewed in order to provide clinicians with a practical and updated guide on how to manage this life-threatening condition.

RESULTS

The clinical presentation of catecholamine-secreting tumors can be deceptive and mimic common disorders of pregnancy. Silent catecholamine-secreting tumors can become evident during pregnancy, and hypertension cannot be considered a hallmark for this condition: some women may be normotensive or develop orthostatic hypotension. Biochemical screening includes measurement of plasma free metanephrines or urinary fractioned metanephrines. Measurement of catecholamines, dopamine, and methoxytyramine can provide further information on tumor biology, location, and prognosis. Diagnostic imaging is limited, and medical treatment requires a cautious balance between hemodynamic control and effects on the fetoplacental unit. Several genes have been associated with syndromes including catecholamine-secreting tumors, and positive genetic testing can correlate with tumor behavior. Timing and modalities for tumor removal and delivery, including anesthetic management, depend on gestational age, maternal and fetal wellbeing, control of catecholamine excess, suspicion of multiple or malignant disease, and surgical accessibility to the tumor.

CONCLUSION

A timely diagnosis and a multidisciplinary approach are the keys to improve pregnancy outcomes in patients with a catecholamine-secreting tumor; each case should be managed in a tertiary referral center.

Utility of alpha-blockade in a hypotensive pheochromocytoma patient with myocardial infarction

OBJECTIVE

The aim of this case study is to emphasize the importance of α-blockade in managing a rare complication of an untreated pheochromocytoma.

CLINICAL PRESENTATION AND INTERVENTION

A 41-year-old man with previous bilateral pheochromocytoma presented with chest pain. He was suffering from cardiac failure and persistent hypotension requiring an inotrope. Cardiac markers, an electrocardiogram and an echocardiogram confirmed acute myocardial infarct with poor ejection fraction and global hypokinesia. An (18)F-fluorodeoxyglucose PET/CT scan showed progressive left suprarenal and organ of Zuckerkandl pheochromocytomas. Blood pressure stabilisation proved challenging but was achieved by titrating an incremental dose of α-blocker against a tapering inotropic dose.

CONCLUSION

This case showed the efficacy of an α-blocker despite persistent hypotension in a patient with pheochromocytoma-induced cardiomyopathy.

Characterizing genetic variation of adrenergic signalling pathways in Takotsubo (stress) cardiomyopathy exomes

AIMS

Exome sequencing was used to genotype comprehensively a Takotsubo (stress) cardiomyopathy (TC) cohort, enabling investigation of a vast 486 gene network for adrenergic signalling.

METHODS AND RESULTS

Twenty-eight TC subjects, including a mother-daughter pair and five recurrent cases, underwent whole-exome sequencing. Frequencies of 17 common, functional adrenergic polymorphisms were statistically similar to those of population controls. Filtering for rare, predicted-deleterious, catecholamine/adrenergic signalling variants revealed heterozygosity in 55 genes in TC cases and 59 genes in healthy controls. Overall allele burden was similar and did not discriminate clinical variables among TC subjects, but gene identities were largely cohort specific, and TC cases were enriched for variants within functional domains (68% vs. 48%, P = 0.031). Two-thirds of TC cases carried more than one filtered adrenergic pathway variant, and 11 genes harboured a variant in ≥ 2 cases. The mother-daughter pair shared missense variants in highly conserved functional domains of ADH5, CACNG1, EPHA4, and PRKCA. An adrenergic pathway-independent analysis of the cohort exposed no common gene for TC.

CONCLUSIONS

Overall, these data support genetic heterogeneity in TC susceptibility and a likely polygenic basis, conferring a cumulative effect on adrenergic pathway dysregulation in a subset of individual subjects. Study of larger cohorts and non-coding regulatory regions is warranted to define genetic risk factors for TC further.

Pheochromocytoma crisis presenting with cardiogenic shock

Pheochromocytoma is a catecholamine-secreting tumor of the adrenal glands whose typical presentation includes the triad of headache, palpitations, and diaphoresis. Pheochromocytoma crisis is an urgent medical condition whose diagnosis and management constitute a challenge for physicians. We present the case of a 55-year-old man who developed cardiogenic shock in the setting of a pheochromocytoma crisis. After stabilizing blood pressure with combined administration of α- and β-blockers, the tumor was surgically removed. Our diagnostic and therapeutic challenges are discussed.

Norepinephrine transporter function and human cardiovascular disease

Approximately 80-90% of the norepinephrine released in the brain or in peripheral tissues is taken up again through the neuronal norepinephrine transporter (NET). Pharmacological studies with NET inhibitors showed that NET has opposing effects on cardiovascular sympathetic regulation in the brain and in the periphery. Furthermore, NET is involved in the distribution of sympathetic activity between vasculature, heart, and kidney. Genetic NET dysfunction is a rare cause of the postural tachycardia syndrome. The condition is characterized by excessive adrenergic stimulation of the heart, particularly with standing. Conversely, NET inhibition may be beneficial in hypoadrenergic states, such as central autonomic failure or neurally mediated syncope, which results from acute sympathetic withdrawal. Biochemical studies suggested reduced NET function in some patients with essential hypertension. Furthermore, cardiac NET function appears to be reduced in common heart diseases, such as congestive heart failure, ischemic heart disease, and stress-induced cardiomyopathy. Whether NET dysfunction is a consequence or cause of progressive heart disease in human subjects requires further study. However, studies with the nonselective NET inhibitor sibutramine suggest that reduced NET function could have an adverse effect on the cardiovascular system. Given the widespread use of medications inhibiting NET, the issue deserves more attention.

Pheochromocytoma presenting as acute decompensated heart failure reversed with medical therapy

A 26-year-old woman presented to hospital with acute chest pain, hypertension, tachycardia and an elevated serum creatinine. She developed respiratory distress requiring endotracheal intubation and mechanical ventilation. She progressed to multiorgan failure due to decompensated congestive heart failure. Echocardiography demonstrated global hypokinesis and an ejection fraction of <10%. Her cardiac function improved with fluid resuscitation and β blockade, and she was eventually discharged home. She was readmitted a few days later with pancreatitis after presenting with nausea, abdominal pain and hypertension. During hospitalisation she had paroxysms of headache, nausea and diaphoresis associated with hypertension and tachycardia. A CT scan of her abdomen revealed an adrenal mass and serum metanephrine studies confirmed the diagnosis of pheochromocytoma. After fluid resuscitation and sympathetic blockade her ejection fraction improved to 55%. The patient underwent an uneventful adrenalectomy and made a complete recovery.

Pheochromocytoma presenting with Takotsubo syndrome

The clinical presentation of Takotsubo syndrome, or apical ballooning syndrome, resembles an extensive anterolateral myocardial infarction with chest pain symptoms and electrocardiographic ST-elevation or T-wave inversion noted in most patients. However, coronary arteries are invariably found to be normal or to display minimal atherosclerotic disease despite modest elevation of cardiac enzymes. Since most cases of Takotsubo syndrome occur after intense physical and/or emotional stress, catecholamine surge appears to be a common underlying mechanism. We present a case of Takotsubo syndrome, which presented with unusual symptoms and was found to be caused by pheochromocytoma. A sudden rise in blood pressure moments after completion of echocardiographic stress testing aided in uncovering the diagnosis.

Takotsubo-like cardiomyopathy in pheochromocytoma

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.

Takotsubo cardiomyopathy--the current state of knowledge

Takotsubo cardiomyopathy is defined as acute chest pain during stressful incidents which is associated with ST-segment abnormalities and/or increased serum troponin levels. There is also regressive systolic dysfunction which is usually localized in the apical and medial left ventricles but there are no significant coronary artery lesions. The ventricular asynergy is also described in the right ventricle but is less common. Almost all the patients are women. The onset of this disease is typically triggered by an acute emotional or stress event or by an accumulation of trivial and repetitive stresses. The etiology of this syndrome remains unclear. Myocardial ischemia and reperfusion due to microvascular spasm, aborted myocardial infarction and related no-reflow phenomenon have been proposed as inducers of Takotsubo cardiomyopathy. The temporal relationship between the stressful event and the triggering of the clinical syndrome as well as the report of elevated catecholamine plasma levels during the acute phase suggest a possible involvement of the sympathetic nervous system. A smaller left ventricular size and hormonal disturbances in women may also play a role.