Journal List > Endocrinol Metab > v.27(1) > 1085997

Jang, Kwon, Lee, Jung, Bae, Kim, and Lee: A Case of Malignant Pheochromocytoma Presenting as Inverted Takotsubo-Like Cardiomyopathy

Abstract

Takotsubo cardiomyopathy or stress induced cardiomyopathy is characterized by acute transient left ventricular apical ballooning without significant coronary artery disease. The pathophysiology of Takotsubo cardiomyopathy remains unclear, but it has been suggested that the stress related neurohumoral factors, especially catecholamines, play an important role. Recently, several reports have described an inverted Takotsubo cardiomyopathy, which is characterized by the dysfunction of the basal and mid-ventricular segments sparing the apex of the heart. In this report, we present a case of a 50-year-old female with a transient left ventricular dysfunction in an inverted Takotsubo pattern, that later was diagnosed as a malignant pheochromocytoma.

Figures and Tables

Fig. 1
The chest X-ray before (A) and after the symptom developed (B). A. Normal chest X-ray without cardiomegaly and pulmonary congestion. B. Increased pulmonary vascular marking and pulmonary edema around perihilar area.
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Fig. 2
Transthoracic echocardiography on admission. A. End systole. B. End diastole. It shows basal akinesia and thinning at mid to basal inferior wall with apical sparing.
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Fig. 3
A. Enhanced abdomino-pelvic computed tomography (APCT) scan. B & C, I-123 metaiodobenzylguanethidine (MIBG) scan. A. APCT shows a 5.2 × 3 cm-sized round, lobulated mass with internal cystic change (arrow) adjacent to the right kidney. B & C. Post 4 hour and 1 day after I-123 MIBG injection. Increased I-123 MIBG uptake at right adrenal gland (circle) and focal increased I-123 MIBG uptake in L4 and left ilium (arrows), suggesting right adrenal gland pheochromocytoma with metastatic lesion.
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Fig. 4
Histologic finding of right adrenal gland. A. Large and pinkish cells with pleomorphic nuclei and prominent nucleoli (H&E stain, × 400). B. Immunohistochemistry for chromogranin was positive in tumor cells (chromogranin, × 400). C. Synaptophysin staining was positive (synaptophysin, × 400). D. Immunohistochemical stain for sustentacular cell, S-100 was positive reaction (S-100, × 200). These findings confirmed the diagnosis of pheochromocytoma.
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Table 1
Serial follow-up of cardiac enzymes during hospitalization
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Table 2
Clinical characteristics of patients with pheochromocytoma associated Takotsubo-like cardiomyopathy (TTC) in Korea
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CAG, coronary angiography; EchoCG, echocardiography; F, female; LV, left ventricle; M, male; Tn-I, troponin I.

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