A Rare Cause of Cardiac Tamponade: Pheochromocytoma

Patients with pheochromocytoma present with paroxysmal headaches, palpitations, excessive sweating, and may have cardiac manifestations such as pericardial effusion and heart failure. We describe a patient with cardiac tamponade who was found to have a previously undiagnosed pheochromocytoma.

Case Description:

A 53-year-old female with hypertension and recently diagnosed stress-induced cardiomyopathy s/p STEMI presented with fever, malaise, headache, and shortness of breath for 2 days. She was found to have pneumonia and was admitted to the hospital. Chest CT scan revealed small pericardial effusion and incidental right adrenal mass 4.0 x 3.5 cm. MRI abdomen with contrast demonstrated enhancing right adrenal mass 4.1 x by 3.6 cm containing fluid indicating cystic change or necrosis. In retrospect the patient endorsed palpitations, headaches, and diaphoresis over the last 3 years. During hospitalization, she experienced tachycardia with heart rate 170 bpm, hypertension with blood pressure (BP) 160/110 mmHg, and headaches. EKG showed sinus tachycardia. Lab results revealed urinary metanephrine-to-creatinine ratio 5420 mcg/gm Cr, plasma metanephrine 13.75 nmol/L, plasma normetanephrines 0.92 nmol/L, plasma aldosterone < 3.0 ng/dL, renin 1.8 ng/mL/hr, ACTH 5.6 pg/mL and AM cortisol 38.6 mcg/dL. She was started on prazosin for BP control and diltiazem for heart rate control.

Unfortunately, the patient developed severe thrombocytopenia, altered mentation and hemodynamic instability with BP 40/20 mmHg requiring transfer to the ICU for intubation and vasopressors. Bedside ultrasound revealed cardiac tamponade, but the patient was not a candidate for surgical intervention due to severe thrombocytopenia and risk of bleeding. After a family meeting, the patient was transitioned to comfort care and died later that day.

Discussion:

Pheochromocytoma has a wide range of presentations. Up to 40% of patients are asymptomatic and present with only an adrenal incidentaloma. We report this case to raise providers’ awareness of the rare life-threatening presentation of pheochromocytoma. Providers evaluating a patient with stress-induced cardiomyopathy should consider catecholamine-induced cardiomyopathy in the setting of unrecognized pheochromocytoma. The pathophysiology includes catecholamine-associated vasoconstriction and direct toxic effect on myocardium. Therefore, clinicians should have a high index of suspicion when patients present with these symptoms because early surgical intervention can be lifesaving.