SPC365

A Broken Heart in the Shadow of an Adrenal Tumor

Session: CASOS CLÍNICOS DE INSUFICIÊNCIA CARDÍACA E CUIDADOS INTENSIVOS
Speaker: Filipe Silva Vilela

Congress: CPC 2025
Topic: E. Coronary Artery Disease, Acute Coronary Syndromes, Acute Cardiac Care
Theme: ---
Subtheme: ---
Session Type: Sessão de Casos Clínicos
FP Number: ---
Authors: Filipe Silva Vilela; Carla Oliveira Ferreira; Rodrigo Silva; Inês Conde; Ana Sofia Fernandes; Mónica Dias; Bárbara Rocha; João Faria; Rui Flores; António Gaspar
<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><strong><span style="font-size:10.0pt">Introduction </span></strong></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="font-size:10.0pt"><span style="color:#221e1f">Takotsubo cardiomyopathy (TTC) was first described in Japan in the 1980s. It is described as an acute but often reversible left ventricular dysfunction mainly triggered by emotional or physical stress. </span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="font-size:10.0pt"><span style="color:#221e1f">Multiple variants of TTC have been reported including reverse Takotsubo cardiomyopathy which is a variant characterized by the basal hypokinesis associated with apical hyperkinesis. &nbsp;</span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:12pt"><span style="background-color:white"><span style="font-family:&quot;Times New Roman&quot;,serif"><span style="font-size:10.0pt"><span style="font-family:&quot;Calibri&quot;,sans-serif"><span style="color:black">The pathophysiological mechanisms are incompletely understood, but there is considerable evidence that sympathetic stimulation is central to its pathogenesis, and it has been associated with conditions of catecholamine excess (e.g. pheochromocytoma, central nervous system disorders).</span></span></span></span></span></span></p>

<p style="text-align:justify">&nbsp;</p>

<p style="text-align:justify"><span style="font-size:12pt"><span style="background-color:white"><span style="font-family:&quot;Times New Roman&quot;,serif"><strong><span style="font-size:10.0pt"><span style="font-family:&quot;Calibri&quot;,sans-serif"><span style="color:black">Clinical Case</span></span></span></strong></span></span></span></p>

<p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:&quot;Times New Roman&quot;,serif"><span style="font-size:10.0pt"><span style="font-family:&quot;Calibri&quot;,sans-serif">We present the case of a 32-year-old woman, 36 weeks pregnant, with no significant medical history. </span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:&quot;Times New Roman&quot;,serif"><span style="font-size:10.0pt"><span style="font-family:&quot;Calibri&quot;,sans-serif">She was admitted to the emergency department with complaints of headache, vomiting, and elevated blood pressure. The analytical study showed an increased urinary protein/creatinine ratio that in the clinical context, a likely diagnosis of preeclampsia with severe features was considered, leading to urgent cesarean.</span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:&quot;Times New Roman&quot;,serif"><span style="font-size:10.0pt"><span style="font-family:&quot;Calibri&quot;,sans-serif">After the cesarean section, hypoxemic respiratory failure was observed, requiring admission to the intensive care unit. For further clarification, a chest CT angiography was performed, which revealed a bilateral ground-glass opacification pattern suggestive of pulmonary congestion, as well as a large nodular formation in the right adrenal gland (35mm).</span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:&quot;Times New Roman&quot;,serif"><span style="font-size:10.0pt"><span style="font-family:&quot;Calibri&quot;,sans-serif">The analytical study showed elevated NT-proBNP and troponin levels, and she underwent an echocardiogram that revealed moderate depression of left ventricular function (38%), hypokinesia of the mid-basal segments of all left ventricular walls with apical hypercontractility, a pattern suggestive of reverse Takotsubo syndrome.</span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="font-size:10.0pt">The endocrine study to characterize the adrenal gland mass revealed elevated metanephrines and catecholamines. Subsequently, a PET scan was performed, showing a nodular formation with high 18F-DOPA uptake, consistent with the suspicion of pheochromocytoma. </span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="font-size:10.0pt">After stabilization and resolution of respiratory failure, the patient was discharged on medication with phenoxybenzamine and bisoprolol. </span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="font-size:10.0pt">Six months later, she underwent right adrenalectomy without complications. She discontinued her medication and, at present, is asymptomatic, NYHA class I, with normalization of left ventricular function, and without typical paroxysmal episodes of pheochromocytoma.</span></span></span></p>

<p style="text-align:justify">&nbsp;</p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><strong><span style="font-size:10.0pt">Discussion</span></strong></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="font-size:10.0pt">Cases associating takotsubo syndrome with pheochromocytoma have been reported, and from a pathophysiological standpoint, is an expected association, as the excess of catecholamines is one of the main explanations for takotsubo syndrome.</span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="font-size:10.0pt">This case is remarkable for describing the association of two rare conditions, that despite their potential severity, can be effectively managed and reversed with appropriate treatment.</span></span></span></p>

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