WHEN YOU HEAR HOOFBEATS, THINK ZEBRAS: MALIGNANT PHEOCHROMOCYTOMA MASQUERADING AS UNSTABLE ANGINA

WHEN YOU HEAR HOOFBEATS, THINK ZEBRAS: MALIGNANT PHEOCHROMOCYTOMA MASQUERADING AS UNSTABLE ANGINA

Young S; Ahmed A; Saling M

Journal Of The American College Of Cardiology

2021

2021-05-03

Pheochromocytomas are rare tumors with less than 0.8 per 100,000 person years. Despite an asymptomatic presentation being most common, the classic triad of symptoms including episodic headaches, paroxysmal sweating and tachycardia is present in less than half of cases with rarer manifestations being orthostatic hypotension, cardiomyopathy or pheochromocytoma crisis. Diagnosis is made by measuring serum or urine metanephrines followed by tumor visualization via CT. Treatment is alpha and beta blockade followed by surgical removal. However, 10% of pheochromocytomas are malignant, which are incurable. We present a malignant pheochromocytoma presenting as unstable angina.

A 65 year old man with a history of CAD, hypertension and diabetes presented for abrupt onset crushing chest pain at rest and was admitted for inpatient evaluation of ACS. There were no EKG changes or elevation in cardiac markers. Several hours after being admitted, the patient developed sudden shortness of breath and abdominal pain. CTA chest showed a small acute distal right lower lobe pulmonary embolism. CT abdomen and pelvis showed a 15 cm heterogenous mass of the left adrenal with extensive metastatic lesions in the liver. Serum metanephrines were significantly elevated and subsequent liver biopsy showed adrenal origin. The patient was discharged home with palliative care.

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Case Report

NEOMED College of Medicine

Department of Internal Medicine

Jan to Aug list 2021