An unusual presentation of pheochromocytoma accompanied by catecholamine-induced cardiomyopathy

IF 3.7 2区 医学 Q2 CARDIAC & CARDIOVASCULAR SYSTEMS
Hugh O.J. Roberts, Alexandru Munteanu, Jonas E. Mertens
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Familial cases are more likely to present with bilateral pheochromocytomas or multifocal paragangliomas. All known familial syndromes associated with these tumours follow an autosomal dominant pattern of inheritance, including Von Hippel–Lindau (VHL) syndrome, multiple endocrine neoplasia type 2 (MEN2) and neurofibromatosis type 1 (NF1). The prevalence of pheochromocytoma in individuals with these syndromes is approximately 10%–20% for VHL, 50% for MEN2 and 2%–3% for NF1. Symptoms typically include at least two of the ‘classic triad’: headache, sweating and tachycardia.<span><sup>2</sup></span> Hypertension is the most frequent symptom, although 10% of patients are normotensive.<span><sup>1</sup></span> Rarely, pheochromocytoma is associated with cardiomyopathy attributed to catecholamine excess (catecholamine-induced cardiomyopathy, CICM) that is similar to stress-induced cardiomyopathy (also known as takotsubo syndrome, TTS).<span><sup>3</sup></span> Twenty-nine percent of pheochromocytomas are malignant, but the commonest causes of mortality are complications related to high circulating levels of catecholamines, including stroke, acute renal failure, ischaemic heart disease, arrhythmias, heart failure and pulmonary oedema.<span><sup>4, 5</sup></span> Definitive management is by resection, requiring careful surgical technique and anaesthesia management to avoid inducing catecholamine release and subsequent uncontrolled hypertension. Principles of management of paragangliomas are the same, but anatomical location can make resection challenging. The most typical paraganglioma sites are the carotid body, jugular bulb, middle ear and vagus nerve, and lower cranial nerve deficits are frequent complications of surgery.<span><sup>6</sup></span> Genetic testing is recommended for all individuals diagnosed with catecholamine-secreting tumours and is typically performed following resection and histopathological confirmation. In cases where a hereditary syndrome is identified, genetic evaluation is also indicated for first-degree relatives to facilitate early detection and management.</p><p>A 39-year-old female patient presented to the emergency department with intractable vomiting and a 2-year history of recurrent shaking episodes with palpitations, tingling in her limbs and hot flushes. Migraine associated with nausea and vomiting often followed these episodes. 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引用次数: 0

Abstract

Pheochromocytomas are catecholamine-secreting tumours arising from chromaffin cells in the adrenal medulla. They are rare, with an annual incidence in Europe of 0.2 per 100 000 people.1 Diagnosis is challenging due to their rarity and non-specific symptoms. Half are discovered incidentally on computed tomography (CT) or magnetic resonance imaging (MRI). These tumours are histologically indistinguishable from extra-adrenal catecholamine-secreting neoplasms, commonly referred to as paragangliomas. The majority of catecholamine-secreting tumours occur sporadically; however, approximately 40% are associated with hereditary syndromes. Familial cases are more likely to present with bilateral pheochromocytomas or multifocal paragangliomas. All known familial syndromes associated with these tumours follow an autosomal dominant pattern of inheritance, including Von Hippel–Lindau (VHL) syndrome, multiple endocrine neoplasia type 2 (MEN2) and neurofibromatosis type 1 (NF1). The prevalence of pheochromocytoma in individuals with these syndromes is approximately 10%–20% for VHL, 50% for MEN2 and 2%–3% for NF1. Symptoms typically include at least two of the ‘classic triad’: headache, sweating and tachycardia.2 Hypertension is the most frequent symptom, although 10% of patients are normotensive.1 Rarely, pheochromocytoma is associated with cardiomyopathy attributed to catecholamine excess (catecholamine-induced cardiomyopathy, CICM) that is similar to stress-induced cardiomyopathy (also known as takotsubo syndrome, TTS).3 Twenty-nine percent of pheochromocytomas are malignant, but the commonest causes of mortality are complications related to high circulating levels of catecholamines, including stroke, acute renal failure, ischaemic heart disease, arrhythmias, heart failure and pulmonary oedema.4, 5 Definitive management is by resection, requiring careful surgical technique and anaesthesia management to avoid inducing catecholamine release and subsequent uncontrolled hypertension. Principles of management of paragangliomas are the same, but anatomical location can make resection challenging. The most typical paraganglioma sites are the carotid body, jugular bulb, middle ear and vagus nerve, and lower cranial nerve deficits are frequent complications of surgery.6 Genetic testing is recommended for all individuals diagnosed with catecholamine-secreting tumours and is typically performed following resection and histopathological confirmation. In cases where a hereditary syndrome is identified, genetic evaluation is also indicated for first-degree relatives to facilitate early detection and management.

A 39-year-old female patient presented to the emergency department with intractable vomiting and a 2-year history of recurrent shaking episodes with palpitations, tingling in her limbs and hot flushes. Migraine associated with nausea and vomiting often followed these episodes. Episodes had increased in frequency and now occurred daily, disrupting her life as a teacher. Despite review in a neurology clinic, no diagnosis had been established. In the emergency department, she was hypotensive, and bedside echocardiogram demonstrated global hypokinesia. Initial troponin was 543 ng/L, N-terminal pro-B-type natriuretic peptide (NT-proBNP) was 689 pmol/L and an electrocardiogram (ECG) demonstrated normal sinus rhythm with no ischaemic changes. She was admitted to intensive care for treatment with dobutamine and norepinephrine. Formal transthoracic echocardiogram showed left ventricle mid-segment hypokinesia and a left ventricular ejection fraction of 33%, in keeping with mid-ventricular variant TTS (see Figure 1). Coronary angiogram was normal.

Over 2 days on intensive care, the dobutamine and norepinephrine were weaned. The episodes of shaking, vomiting, and headache continued throughout the admission, and were associated with hypertension and ventricular ectopics. Once vasopressors and inotropes were discontinued, urine metanephrines were collected and were found to be grossly elevated. Phenoxybenzamine and bisoprolol were started for suspected pheochromocytoma. Prior to discharge, repeat echocardiogram showed normokinesis of all wall segments, and an improved ejection fraction of 62%. Outpatient CT confirmed a 55 mm adrenal pheochromocytoma, and laparoscopic adrenalectomy was performed 2 months later. Histology identified a clear resection margin and a low grading of adrenal pheochromocytoma and paraganglioma (GAPP) score, indicating a well differentiated type with a low risk of malignancy.7 Thirteen months post-adrenalectomy, the patient reported no further episodes of shaking and associated symptoms or migraine since surgery. Plasma metanephrines were normal at 6 months and CT at 1 year showed no evidence of tumour recurrence.

We describe an atypical presentation of pheochromocytoma, with CICM and hypotension. Pheochromocytoma diagnosis requires testing for metanephrines, but multiple drugs may interfere with these. CICM presents similarly to TTS, and several echocardiographic phenotypes have been described. More cases are required to determine the association of different phenotypes with different syndromes.

The authors have no conflicts of interests or external funding to disclose.

Abstract Image

罕见的嗜铬细胞瘤伴儿茶酚胺引起的心肌病。
嗜铬细胞瘤是由肾上腺髓质的嗜铬细胞引起的分泌儿茶酚胺的肿瘤。它们很罕见,在欧洲每年的发病率为每10万人中有0.2人由于其罕见和非特异性症状,诊断具有挑战性。其中一半是在计算机断层扫描(CT)或磁共振成像(MRI)上偶然发现的。这些肿瘤在组织学上与肾上腺外分泌儿茶酚胺的肿瘤难以区分,通常被称为副神经节瘤。大多数分泌儿茶酚胺的肿瘤是零星发生的;然而,大约40%与遗传性综合征有关。家族性病例更可能表现为双侧嗜铬细胞瘤或多灶副神经节瘤。所有已知的与这些肿瘤相关的家族性综合征都遵循常染色体显性遗传模式,包括Von Hippel-Lindau (VHL)综合征、多发性内分泌瘤2型(MEN2)和1型神经纤维瘤病(NF1)。在这些综合征的个体中,嗜铬细胞瘤的患病率约为VHL的10%-20%,MEN2的50%和NF1的2%-3%。典型的症状包括至少两种“经典三联征”:头痛、出汗和心动过速高血压是最常见的症状,尽管10%的患者血压正常很少,嗜铬细胞瘤与儿茶酚胺过量引起的心肌病(儿茶酚胺诱导的心肌病,CICM)有关,类似于应激性心肌病(也称为takotsubo综合征,TTS)29%的嗜铬细胞瘤是恶性的,但最常见的死亡原因是与高循环儿茶酚胺水平相关的并发症,包括中风、急性肾功能衰竭、缺血性心脏病、心律失常、心力衰竭和肺水肿。4,5最终的治疗是切除,需要仔细的手术技术和麻醉管理,以避免诱导儿茶酚胺释放和随后不受控制的高血压。副神经节瘤的处理原则是相同的,但解剖位置可以使切除具有挑战性。最典型的副神经节瘤发生部位为颈动脉体、颈静脉球、中耳和迷走神经,下颅神经缺损是手术常见的并发症建议对所有诊断为儿茶酚胺分泌肿瘤的个体进行基因检测,通常在切除和组织病理学确认后进行。在发现遗传综合征的情况下,还建议对一级亲属进行遗传评估,以促进早期发现和治疗。39岁女性患者因难治性呕吐及2年复发性震颤发作伴心悸、四肢刺痛及潮热就诊急诊科。偏头痛常伴有恶心和呕吐。发作的频率增加了,现在每天都发生,扰乱了她作为教师的生活。尽管在神经病学诊所复查,没有确诊。在急诊科,她出现低血压,床边超声心动图显示全身运动不足。初始肌钙蛋白为543 ng/L, n端前b型利钠肽(NT-proBNP)为689 pmol/L,心电图显示窦性节律正常,无缺血改变。她被送进重症监护室接受多巴酚丁胺和去甲肾上腺素的治疗。经胸超声心动图显示左心室中段运动功能减退,左心室射血分数为33%,与中心室变异型TTS相符(见图1)。冠状动脉造影正常。在重症监护2天后,停用多巴酚丁胺和去甲肾上腺素。在入院期间,震颤、呕吐和头痛持续发作,并伴有高血压和心室异位。一旦停用血管加压药和肌力药物,收集尿中肾上腺素,发现其明显升高。疑似嗜铬细胞瘤开始使用苯氧苄胺和比索洛尔。出院前,重复超声心动图显示所有壁段运动正常,射血分数提高62%。门诊CT证实为55毫米肾上腺嗜铬细胞瘤,2个月后行腹腔镜肾上腺切除术。组织学发现切除边缘清晰,肾上腺嗜铬细胞瘤和副神经节瘤(GAPP)评分低,提示分化程度高,恶性风险低肾上腺切除术后13个月,患者报告手术后没有再发生震颤和相关症状或偏头痛。6个月时血浆肾上腺素正常,1年CT未见肿瘤复发。我们描述了一个不典型的嗜铬细胞瘤的表现,伴有CICM和低血压。嗜铬细胞瘤的诊断需要检测肾上腺素,但多种药物可能会干扰这些检测。 CICM的表现与TTS相似,并且已经描述了几种超声心动图表型。需要更多的病例来确定不同表型与不同综合征的关联。作者没有任何利益冲突或外部资金需要披露。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
ESC Heart Failure
ESC Heart Failure Medicine-Cardiology and Cardiovascular Medicine
CiteScore
7.00
自引率
7.90%
发文量
461
审稿时长
12 weeks
期刊介绍: ESC Heart Failure is the open access journal of the Heart Failure Association of the European Society of Cardiology dedicated to the advancement of knowledge in the field of heart failure. The journal aims to improve the understanding, prevention, investigation and treatment of heart failure. Molecular and cellular biology, pathology, physiology, electrophysiology, pharmacology, as well as the clinical, social and population sciences all form part of the discipline that is heart failure. Accordingly, submission of manuscripts on basic, translational, clinical and population sciences is invited. Original contributions on nursing, care of the elderly, primary care, health economics and other specialist fields related to heart failure are also welcome, as are case reports that highlight interesting aspects of heart failure care and treatment.
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