Halim El Hage, Boutros Karam, Julie Zaidan and Elie El Charabaty
Introduction: Pheochromocytomas are rare catecholamine secreting tumors that arise from the chromaffine tissue of the adrenal medulla. Rarely, these tumors are associated with cardiomyopathy. We herein present a patient with pheochromocytoma presenting initially with congestive heart failure and hypertensive emergency.
Case presentation: A 62-year-old female with no past medical history presented to the emergency department for dyspnea and lower extremity edema of 2 weeks duration. The patient was tachycardic at 120 BPM, hypertensive at 197/90 mmHg. She had decreased breath sounds bilaterally. Electrocardiogram showed sinus tachycardia. Chest x-ray revealed bilateral pulmonary infiltrates and effusions. Laboratory testing demonstrated a white blood cell count of 18.06 TH/mm3 , platelet count of 693 TH/mm3 , D-dimer of 540 ng/ml, and a brain natriuretic peptide of 888pg/ml. A lower extremity duplex was negative for venous thromboembolism. Computed tomography scan of the chest ruled out pulmonary embolism. An Echocardiogram showed diffuse hypokinesis, and an estimated ejection fraction of 35 percent. Thyroid stimulating hormone, Urine and plasma metanephrines and renal artery duplex were done as part of the workup. Renal ultrasound and arterial Doppler were negative for renal artery stenosis, but revealed a right upper pole partially solid mass. An MRI of the abdomen confirmed a mass in the upper pole of the right kidney. Initial laboratory tests showed elevated plasma Metanephrines at 8065 pg/ml and urine metanephrines at 1594 mcg/g. The patient was started on Phenoxybenzamine. Surgical resection with histo-pathological examination performed 4 weeks later confirmed the diagnosis of pheochromocytoma.
Discussion: Pheochromocytomas are rare tumors, associated with a number of cardiovascular complications. The acute onset of severe congestive heart failure secondary to catecholamine overproduction is a rare entity, and is associated with a poor prognosis.This case teaches us, that in patients presenting with heart failure with no obvious cause, the diagnosis of pheochromocytoma should always be contemplated.
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