Z026

 

Phaeochromocytoma presenting as an acute coronary syndrome

 

S 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 NHS Trust

 

 

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 weekly.

 

Subsequent investigations 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 and sweating.