Category: Adrenal Disorders

Monitor: 26

26 - GENERALIZED ANXIETY DISORDER AND ADRENERGIC CARDIOMYOPATHY AS INITIAL PRESENTATION OF PHEOCROMOCYTOMA

Thursday, Apr 25
12:00 PM – 12:30 PM

Objective :

Pheocromocytomas are rare catecholamine-secreting tumors that result in life threatening hypertensive episodes.The excess of circulating catecholamines may give rise to different cardiovascular disorders that range from silent myocardial alterations to hypertensive emergencies, myocardial infarction and exceptionally cardiogenic shock.
We present the case of a 30-year-old male patient, with history of generalized anxiety disorder characterized by episodes of palpitations, tremor, sweat, anguish and chest pain, he was treated with clonazepam and fluoxetine. He is admitted to our hospital with an episode characterized by extreme anxiety and vomiting. Upon physical examination his BP was found to be 240/120mmHg; he was treated as a hypertensive urgency and was sent home. On the way home he resumed vomiting, and was admitted to another hospital with palpitations, sweat, and feeling of impending death, his BP was not audible at the time. 


Methods : n/a


Results : n/a


Discussion : An echocardiogram showed LVH, and hypokinesia, LVEF:20%. Troponins: >2000(<50 ng/L), CPK-Mb 18.1 ng/dl (<7ng/dl), PRO BNP: 1647 pg/ml (<100 pg/ml). He was retransferred to our hospital, admitted with cardiogenic shock diagnosis and non-STEMI Killip IV. He received treatment with aspirin, clopidogrel, atorvastatine and vasoactive amines for five days, with complete recovery, released with enalapril 5 mg/day and bisoprolol 2.5 mg/day. He returned 24 hours later with chest pain and palpitations and was admitted with a new non-STEMI. His vital signs were BP:210/110mmHg, HR:160bpm, troponins 253ng/L. Endocrine consult suggested screening for secondary hypertension. A renal Doppler scan was normal;plasma metanephrines: 2550pg/ml, urinary metanephrines: 3610ug/L, plasma normetanephrines: 1410pg/ml and urinary normetanephrines: 1210ug/dl. An abdominal CT was performed, reporting a heterogeneous and lobulated mass located in the left adrenal gland, enhanced on IV contrast without calcifications, measuring 6x4.5x5.5cm. Alpha and beta adrenergic blockade was started with doxazosin and verapamil. Screening for MEN-2 resulted negative. A laparoscopic left adrenalectomy was performed, obtaining an 8x5cm mass, without complications. The biopsy described a well delimited neoplasia with capsular invasion, cells with oncocytic cytoplasm, 1-2 round and oval nuclei and moderate pleomorphism, with trabecular pattern separated by fibrous and vascularized bands and no necrosis. 


Conclusion :

Surgery is the treatment of choice in these patients. Myocardial affections in adrenergic cardiomyopathies are reversible after complete tumor resection. Our patient is now 3 months post surgery, and has normal echocardiographic findings at this time.

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Maria Alejandra Ramos Guifarro

Chief of Endocrinology
Hospital Escuela Universitario
Tegucigalpa, Francisco Morazan, Honduras

Chief of Endocrinology Hospital Escuela

Gerson Andino

Endocrinologist
Hospital Escuela Universitario

.

Daniel Andres Guifarro Rivera

Medical Student
Universidad Nacional Autónoma de Honduras

.

Roberto Esquivel

Surgeon
Hospital Escuela Universitario

.

Ana Raquel Morales

Surgeon
Hospital Escuela Universitario

.

Mazlova Toledo

Pathologist
Hospital Escuela Universitario, Francisco Morazan, Honduras

.

Maria Alejandra Ramos

Carlos Rivera