Heart and Vessels

, Volume 28, Issue 2, pp 255–263

Endomyocardial biopsy in a patient with hemorrhagic pheochromocytoma presenting as inverted Takotsubo cardiomyopathy

  • Kohei Iio
  • Shunpei Sakurai
  • Tamon Kato
  • Shigeki Nishiyama
  • Takeki Hata
  • Eiichiro Mawatari
  • Chihiro Suzuki
  • Kazuhiro Takekoshi
  • Kayoko Higuchi
  • Toru Aizawa
  • Uichi Ikeda
Case Report

Abstract

A 29-year-old female patient presented with shock and dyspnea due to heart failure and pulmonary edema. Echocardiography indicated excessive contraction limited to the left ventricular apex and akinesis of the basal and middle ventricle, which were confirmed by emergency left ventriculography. The finding was diagnostic of inverted Takotsubo cardiomyopathy. An abdominal computed tomography scan showed a tumor in the left adrenal gland with a central low-density area, and the plasma and urinary catecholamines were strikingly elevated. Taken together, these findings suggested the presence of a hemorrhagic pheochromocytoma. A myocardial biopsy in the very acute stage on the day of admission revealed neutrophilic infiltration and contraction-band necrosis, which was indistinguishable from the previously reported pathology in the acute phase of idiopathic Takotsubo cardiomyopathy without pheochromocytoma. The diagnosis of pheochromocytoma in this case was confirmed 7 weeks later by surgical removal of the left adrenal gland with massive hemorrhage at the center of the pheochromocytoma. The marked similarity of the endomyocardial pathology between this case and cases with idiopathic Takotsubo cardiomyopathy strongly points to catecholamine excess as a common causality for Takotsubo cardiomyopathy with or without pheochromocytoma.

Keywords

Pheochromocytoma Takotsubo cardiomyopathy Endomyocardial biopsy Shock 

References

  1. 1.
    Tyce GM, Sheps SG, Carney JA (1972) Pheochromocytoma. Fine structural, biochemical and clinical observations. Am J Cardiol 30:197–204PubMedCrossRefGoogle Scholar
  2. 2.
    Bravo EL, Tagle R (2003) Pheochromocytoma: state-of-the-art and future prospects. Endocr Rev 24:539–553PubMedCrossRefGoogle Scholar
  3. 3.
    Kizer JR, Koniaris LS, Edelman JD, St John Sutton MG (2000) Pheochromocytoma crisis, cardiomyopathy, and hemodynamic collapse. Chest 118:1221–1223PubMedCrossRefGoogle Scholar
  4. 4.
    Sanchez-Recalde A, Costero O, Iborra C, Oliver JM, Ruiz E, Sobrino JA (2006) Pheochromocytoma-related cardiomyopathy: inverted Takotsubo contractile pattern. Circulation 113:e738–e739PubMedCrossRefGoogle Scholar
  5. 5.
    Cho DK, Kim JH, Chung N (2009) Cardiovascular flashlight. Transient mid-ventricular ballooning cardiomyopathy associated with bladder pheochromocytoma. Eur Heart J 30:1202PubMedCrossRefGoogle Scholar
  6. 6.
    Gervais MK, Gagnon A, Henri M, Bendavid Y (2010) Pheochromocytoma presenting as inverted Takotsubo cardiomyopathy: a case report and review of the literature. J Cardiovasc Med (Hagerstown) (Epub ahead of print)Google Scholar
  7. 7.
    Kim S, Yu A, Filippone LA, Kolansky DM, Raina A (2010) Inverted-Takotsubo pattern cardiomyopathy secondary to pheochromocytoma: a clinical case and literature review. Clin Cardiol 33:200–205PubMedCrossRefGoogle Scholar
  8. 8.
    Di Palma G, Daniele GP, Antonini-Canterin F, Piazza R, Nicolosi GL (2010) Cardiogenic shock with basal transient left ventricular ballooning (Takotsubo-like cardiomyopathy) as first presentation of pheochromocytoma. J Cardiovasc Med (Hagerstown) 11:507–510CrossRefGoogle Scholar
  9. 9.
    Satoh H, Tateishi H, Uchida T (1990) Takotsubo-type cardiomyopathy due to multivessel spasm. In: Kodama K, Haze K, Hon M (eds) Clinical aspects of myocardial injury: from ischemia to heart failure. Kagakuhyouronsya, Tokyo, pp 56–64Google Scholar
  10. 10.
    Wittstein IS, Thiemann DR, Lima JA, Baughman KL, Schulman SP, Gerstenblith G, Wu KC, Rade JJ, Bivalacqua TJ, Champion HC (2005) Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med 352:539–548PubMedCrossRefGoogle Scholar
  11. 11.
    Reuss CS, Lester SJ, Hurst RT, Askew JW, Nager P, Lusk J, Altemose GT, Tajik AJ (2007) Isolated left ventricular basal ballooning phenotype of transient cardiomyopathy in young women. Am J Cardiol 99:1451–1453PubMedCrossRefGoogle Scholar
  12. 12.
    Lyon AR, Rees PS, Prasad S, Poole-Wilson PA, Harding SE (2008) Stress (Takotsubo) cardiomyopathy—a novel pathophysiological hypothesis to explain catecholamine-induced acute myocardial stunning. Nat Clin Pract Cardiovasc Med 5:22–29PubMedCrossRefGoogle Scholar
  13. 13.
    Agarwal V, Kant G, Hans N, Messerli FH (2011) Takotsubo-like cardiomyopathy in pheochromocytoma. Int J Cardiol 153:241–248PubMedGoogle Scholar
  14. 14.
    Mariscalco G, Cattaneo P, Rossi A, Baravelli M, Piffaretti G, Scannapieco A, Nassiacos D, Sala A (2010) Takotsubo cardiomyopathy complicated by ventricular septal perforation and septal dissection. Heart Vessels 25:73–75PubMedCrossRefGoogle Scholar
  15. 15.
    Prontera C, Emdin M, Zucchelli GC, Ripoli A, Passino C, Clerico A (2004) Analytical performance and diagnostic accuracy of a fully-automated electrochemiluminescent assay for the N-terminal fragment of the pro-peptide of brain natriuretic peptide in patients with cardiomyopathy: comparison with immunoradiometric assay methods for brain natriuretic peptide and atrial natriuretic peptide. Clin Chem Lab Med 42:37–44PubMedCrossRefGoogle Scholar
  16. 16.
    Arora S, Vargo S, Lupetin AR (2009) Computed tomography appearance of spontaneous adrenal hemorrhage in a pheochromocytoma. Clin Imaging 33:314–317PubMedCrossRefGoogle Scholar
  17. 17.
    Karch SB, Billingham ME (1986) Myocardial contraction bands revisited. Hum Pathol 17:9–13PubMedCrossRefGoogle Scholar
  18. 18.
    Järnberg PO, Bengtsson L, Ekstrand J, Hamberger B (1981) Dopamine infusion in man. Plasma catecholamine levels and pharmacokinetics. Acta Anaesthesiol Scand 25:328–331PubMedCrossRefGoogle Scholar
  19. 19.
    Regan CJ, Duckworth R, Fairhurst JA, Maycock PF, Frayn KN, Campbell IT (1990) Metabolic effects of low-dose dopamine infusion in normal volunteers. Clin Sci 79:605–611PubMedGoogle Scholar
  20. 20.
    Neumann HP, Bausch B, McWhinney SR, Bender BU, Gimm O, Franke G, Schipper J, Klisch J, Altehoefer C, Zerres K, Januszewicz A, Eng C, Smith WM, Munk R, Manz T, Glaesker S, Apel TW, Treier M, Reineke M, Walz MK, Hoang-Vu C, Brauckhoff M, Klein-Franke A, Klose P, Schmidt H, Maier-Woelfle M, Peçzkowska M, Szmigielski C, Eng C; Freiburg-Warsaw-Columbus Pheochromocytoma Study Group (2002) Germ-line mutations in nonsyndromic pheochromocytoma. N Engl J Med 346:1459–1466Google Scholar
  21. 21.
    Gimenez-Roqueplo AP, Burnichon N, Amar L, Favier J, Jeunemaitre X, Plouin PF (2008) Recent advances in the genetics of phaeochromocytoma and functional paraganglioma. Clin Exp Pharmacol Physiol 35:376–379PubMedCrossRefGoogle Scholar
  22. 22.
    Nef HM, Möllmann H, Troidl C, Weber M, Hamm C, Elsässer A (2008) Tako-Tsubo cardiomyopathy: NT-proBNP as a reliable parameter of a favourable prognosis? Int J Cardiol 124:237–238PubMedCrossRefGoogle Scholar
  23. 23.
    Pirzer R, Elmas E, Haghi D, Lippert C, Kralev S, Lang S, Borggrefe M, Kälsch T (2011) Platelet and monocyte activity markers and mediators of inflammation in Takotsubo cardiomyopathy. Heart Vessels. doi:10.1007/s00380-011-0132-6
  24. 24.
    Kawai S, Kitabatake A, Tomoike H, Takotsubo Cardiomyopathy Group (2007) Guidelines for diagnosis of takotsubo (ampulla) cardiomyopathy. Circ J 71:990–992PubMedCrossRefGoogle Scholar
  25. 25.
    Prasad A, Lerman A, Rihal CS (2008) Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): a mimic of acute myocardial infarction. Am Heart J 155:408–417PubMedCrossRefGoogle Scholar
  26. 26.
    Ennezat PV, Pesenti-Rossi D, Aubert JM, Rachenne V, Bauchart JJ, Auffray JL, Logeart D, Cohen-Solal A, Asseman P (2005) Transient left ventricular basal dysfunction without coronary stenosis in acute cerebral disorders: a novel heart syndrome (inverted Takotsubo). Echocardiography 22:599–602PubMedCrossRefGoogle Scholar
  27. 27.
    Nef HM, Möllmann H, Kostin S, Troidl C, Voss S, Weber M, Dill T, Rolf A, Brandt R, Hamm CW, Elsässer A (2007) Tako-Tsubo cardiomyopathy: intraindividual structural analysis in the acute phase and after functional recovery. Eur Heart J 28:2456–2464PubMedCrossRefGoogle Scholar
  28. 28.
    Nef HM, Möllmann H, Akashi YJ, Hamm CW (2010) Mechanisms of stress (Takotsubo) cardiomyopathy. Nat Rev Cardiol 7:187–193PubMedCrossRefGoogle Scholar
  29. 29.
    Jones DJ, Durning P (1985) Phaeochromocytoma presenting as an acute abdomen: report of two cases. Br Med J 291:1267–1268CrossRefGoogle Scholar
  30. 30.
    Brown H, Goldberg PA, Selter JG, Cabin HS, Marieb NJ, Udelsman R, Setaro JF (2005) Hemorrhagic pheochromocytoma associated with systemic corticosteroid therapy and presenting as myocardial infarction with severe hypertension. J Clin Endocrinol Metab 90:563–569PubMedCrossRefGoogle Scholar
  31. 31.
    James TN (1976) De subitaneis mortibus. XIX. On the cause of sudden death in pheochromocytoma, with special reference to the pulmonary arteries, the cardiac conduction system, and the aggregation of platelets. Circulation 54:348–356PubMedCrossRefGoogle Scholar

Copyright information

© Springer 2012

Authors and Affiliations

  • Kohei Iio
    • 1
    • 6
  • Shunpei Sakurai
    • 1
  • Tamon Kato
    • 1
  • Shigeki Nishiyama
    • 1
  • Takeki Hata
    • 1
  • Eiichiro Mawatari
    • 1
  • Chihiro Suzuki
    • 1
  • Kazuhiro Takekoshi
    • 2
  • Kayoko Higuchi
    • 3
  • Toru Aizawa
    • 4
  • Uichi Ikeda
    • 5
  1. 1.Department of CardiologyAizawa HospitalMatsumotoJapan
  2. 2.Department of Laboratory Medicine, Graduate School of Comprehensive Human SciencesUniversity of TsukubaTsukubaJapan
  3. 3.Department of PathologyAizawa HospitalMatsumotoJapan
  4. 4.Diabetes Center, Aizawa HospitalMatsumotoJapan
  5. 5.Department of CardiologyShinshu University School of MedicineMatsumotoJapan
  6. 6.Department of OrthopedicsHirosaki University School of MedicineHirosakiJapan

Personalised recommendations