Clinical Pearls & Morning Reports
Published March 14, 2018
The relationship between pheochromocytoma and catecholamine-induced shock has been recognized for more than 40 years. Read the latest Case Records of the Massachusetts General Hospital here.
Q: What diagnoses are considered in patients with ventricular apical ballooning in the absence of atherothrombotic coronary artery disease?
A: The finding of ventricular apical ballooning in the absence of atherothrombotic coronary artery disease has a limited differential diagnosis. Key considerations include recurrent apical ballooning syndrome (perhaps due to exercise-induced hypertension), takotsubo cardiomyopathy, acute myocarditis, coronary vasospasm, cocaine-induced coronary vasoconstriction, and thrombosis with endogenous fibrinolysis before angiography.
Q: What characteristic features are generally seen in patients with acute myocarditis?
A: Patients with either takotsubo cardiomyopathy or acute myocarditis can present with cardiovascular collapse, but patients with acute myocarditis generally have the following features: signs or symptoms of infection, ST-segment elevation or depression, a substantially elevated troponin level, localized or diffuse left ventricular wall-motion abnormalities, the presence of many inflammatory cells and interstitial edema on examination of a endomyocardial biopsy specimen, evidence of a viral infection on laboratory testing, and a gadolinium-enhancement pattern on cardiac MRI that is nonischemic in distribution, commonly affects the epicardial zone, and occurs long after disease onset.
A: Takotsubo cardiomyopathy may be primary or secondary. In general, patients with primary takotsubo cardiomyopathy are more likely to present with a chest-pain syndrome, whereas patients with secondary takotsubo cardiomyopathy are more likely to present with heart failure or cardiogenic shock, with correspondingly worse prognoses. Patients with takotsubo cardiomyopathy who have right ventricular involvement have a worse prognosis than those who do not; right ventricular involvement is the only independent predictor of the combined outcome of death from any cause, rehospitalization for heart failure, or recurrent takotsubo cardiomyopathy.
A: Pheochromocytoma is associated with hypocalcemia, especially during crises, most likely as a result of increased expression of adrenomedullin. Adrenomedullin not only is a highly potent vasodilator but also causes proliferation of osteoblasts, promotes bone growth and mineralization, and can lead to calcium sequestration and hypocalcemia. Patients with pheochromocytomas that secrete epinephrine and adrenomedullin may present with hemodynamic instability because of the vasoconstrictor effect of the catecholamine coupled with the profound vasodilator effect of adrenomedullin.