Phaeochromocytoma presenting as an acute coronary syndrome
Azam, A Ostler, SR Mehta, SD Rosen, F Palazzo, Departments of Cardiology and Endocrinology Ealing Hospital, National Heart and Lung
Institute, Imperial College
Endocrine Surgery Hammersmith Hospital, Imperial Healthcare
A 48-year-old man presented to the Emergency Department
with a one-day history of central crushing chest pain and palpitations.
On presentation his initial ECG showed tachycardia with ST depression in
lateral leads. Blood results showed positive and dynamic troponin levels and he
was initiated on treatment for an acute coronary
syndrome (ACS) with dual antiplatelet therapy (DAPT), fondaparinux plus a beta
blocker. There was no significant past medical history or family history of
ischaemic heart disease. He was a smoker and had a moderate intake of alcohol
demonstrated inferior wall hypokinesis with preserved systolic function and
unobstructed coronary arteries. In view of the
angiographic findings, the working diagnosis was myopericarditis likely
secondary to a viral lower respiratory tract
infection (LRTI). However, despite high dose beta blockers and treatment of a
suspected LRTI the patient remained tachycardic and sweaty.
He underwent an ultrasound of the abdomen for investigation
of a potential underlying myeloproliferative disorder on account of thrombocytosis on his blood results. The scan demonstrated a
large solid and cystic adrenal mass suspicious for a phaeochromocytoma. MRI
abdomen reported a heterogeneous mass involving the medial limb of the left
adrenal gland measuring 5.3 x 6 x 5cm. 24-hour
urinary normetanephrines and metaneprhines were elevated at 9860 nmol and
21547.5 nmol respectively.
He was seen by the endocrinology team and alpha blockade
with doxazosin was initiated followed by addition of the beta-blocker propranolol. The patient was referred to the endocrine surgeons and
successfully underwent a laparoscopic adrenalectomy. Histology confirmed a
composite phaechromocytoma and ganglioneuroma, Ki-67 of 2-3% and
immunohistochemistry demonstrated cells expressing synaptophysin and chromogranin. Analysis of 10 phaeochromocytoma
and paraganglioma susceptibility genes did not detect any pathogenic variant.
This case demonstrates that phaeochromocytomas can mimic a
number of cardiac conditions including acute coronary syndrome.
Elevated plasma catecholamines may cause myocardial injury by a direct toxic
effect on myocytes and / or diffuse coronary vasospasm. Phaeochromocytoma
should be considered in the differential diagnosis of patients presenting with
chest pain, uncontrolled blood pressure, palpitations