The paroxysms of tachycardia and arterial hypertension, clinical presentation and sudden worsening after beta-blocker and metoclopramide therapy in this patient raised the suspicion of a pheochromocytoma. Urgent thoracoabdominal computed tomography confirmed the presence of a right adrenal mass (size: 75 × 69 × 73 mm) (Fig. 1). Subsequently, beta-blocker therapy was withheld. Plasmatic and 24-hour urinary catecholamine and metanephrine levels were found to be markedly elevated.
Fig. 1
Computed tomography coronal view confirming presence of right adrenal mass (denoted with asterisk)
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Stepwise alpha-adrenergic blockade with phenoxybenzamine followed by beta-adrenergic blockade with propranolol were undertaken. Blood pressure and heart rate normalised, and her symptoms resolved. Left ventricular abnormalities recovered after 5 days, confirming Takotsubo-like cardiomyopathy. An uneventful right laparoscopic adrenalectomy was performed, and histological examination confirmed the diagnosis of pheochromocytoma. The patient remained asymptomatic and normotensive during follow-up.
Pheochromocytoma is a rare tumour with potentially life-threatening complications. High catecholamine levels can lead to direct cardiotoxicity, resulting in a Takotsubo-like cardiomyopathy presentation [1]. Pheochromocytoma paroxysms can be precipitated by certain conditions, namely exercise, trauma, surgery or specific drugs. The latter include beta-blockers, which promote significative unopposed alpha-mediated vasoconstriction, and metoclopramide, by potentiating additional catecholamine release [2]. In this case, these two drugs probably acted synergistically, leading to clinical worsening and uncovering the cardinal manifestations.
Pheochromocytoma can present with nonspecific symptoms, making this a challenging diagnosis that requires a high index of suspicion. Nevertheless, important red flags are paroxysmal hypertension, the triad of episodic headache, diaphoresis and palpitations, or clinical worsening under the previously mentioned conditions [3]. In patients with Takotsubo-like cardiomyopathy, active surveillance for these signs/symptoms is important as they can expose an unrecognized pheochromocytoma, allowing treatment and avoidance of potentially harmful medications.
Funding
No funding was required for this manuscript.
Conflict of interest
A.F. Cardoso, G. Dias, B. Faria, F. Almeida and A. Lourenço declare that they have no competing interests.
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