WHAT'S BLACK AND WHITE AND STRESSED ALL OVER? A ZEBRA PRESENTATION OF A ZEBRA CASE

Document Type

Conference Proceeding

Publication Date

4-1-2024

Publication Title

J Am Coll Cardiol

Abstract

Background Pheochromocytomas (PHEOS) are rare catecholamine secreting tumors. Rare cases of stress induced cardiomyopathy (SICM) and cardiogenic shock (CGS) have been reported with PHEOS. The management of PHEO related CGS is not well defined. Case A 34 year old male with no past medical history presented to an outside hospital with 3 days of worsening generalized weakness. He was afebrile, hypertensive, and tachycardic. TTE showed a newly reduced LVEF of 10% with global hypo-kinesis and a hyper contractile base, LV apical thrombus, and bi-ventricular dilation. Hospital course was complicated by a subacute infarct in the right parietal lobe, oliguric renal failure, and acute liver injury. He was then transferred to Henry Ford Hospital. A RHC showed elevated systemic pressures and filling pressures, severely reduced cardiac index, and severely increased systemic vascular resistance. He was started on dobutamine, Nipride, emergent dialysis, and a Swan Ganz Catheter (SGC) was placed. He remained hypertensive with high filling pressures and transitioned to a hyperdynamic state. Inotropes were stopped. Review of imaging showed a hypo-dense 3.1cm cystic nodule in the left adrenal gland. Adrenal adenoma work up revealed elevated plasma metanephrines. He was transitioned to maximally titrated medical therapy for HFrEF. He had a successful left adrenalectomy. Pathology was positive for PHEO. On follow up, LV and renal function had recovered. Decision-making TTE suggested SICM or LM/LAD stenosis. LHC was deferred due to the patient's renal dysfunction and low pretest probability of CAD. Escalation to inotropes with SGC was necessary due to CGS progression. Mechanical circulatory support was not pursued because the patient's hemodynamics favored after load reduction and the presence of an intra-cardiac thrombus. SICM has a variety of proposed mechanisms, including excessive catecholamines. Thus, medical treatment focused on reducing sympathetic tone with HFrEF treatment. Definitive treatment was adrenalectomy. Conclusion In the treatment of CGS, this case emphasizes the need for continuous hemodynamic monitoring, a multi-disciplinary team approach, and etiology focused plan.

Volume

83

Issue

13

First Page

3723

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