Pheo still kills

Pheo very rarely causes death in modern times. Whenever a patient dies of pheo, the diagnosis and management of the patient’s pheo require detailed analysis. The lessons learned from such an unfortunate death are invaluable.

I run into a case report published earlier this year. A 61-year-old male suddenly developed fatigue, nausea, vomiting, and shortness of breath. He came to an emergency room 6 hours later. At the emergency room, he initially had high blood pressure and heart rate. His condition deteriorated quickly so that he was intubated. His markers of heart attack were elevated but his coronary arteries were normal. His left heart ventricle exhibited abnormal movement. He was diagnosed with takotsubo cardiomyopathy (a heart disease caused by extreme stress). Chest X-ray showed signs of heart failure and CT showed changes consistent with certain kind of pneumonia. 2 hours later, his blood pressure suddenly dropped and he suffered from cardiac arrest. He died shortly after. It was only 12 hours between the start of symptoms and death. Autopsy found a 4-cm hemorrhagic pheochromocytoma in the right adrenal gland.

This case is typical for pheo-related sudden death. He was apparently healthy before the onset of symptoms. He had no known pheo. His symptoms suggested heart or lung diseases. He initially had high blood pressure and heart rate. Testing and imaging showed he had normal coronary arteries but with other heart and lung abnormalities. He then suddenly developed low blood pressure and cardiac arrest and died quickly.

Was his death avoidable? It is hard to say. Were there potential opportunities to make an early diagnosis of pheo and to institute therapies? There probably were. In any patients with acute heart problems with normal coronary arteries, pheo should be considered. Pheo is a rare cause of heart problems but pheo-related heart problems are reversible. The probability of pheo is much higher after the coronary arteries are shown to be normal. Takotsubo cardiomyopathy cannot be reliably diagnosed without ruling out pheo. Therefore, pheo should be considered in this patient. A particularly odd thing in this case was that the chest CT did not mention the adrenal tumor. Chest CT should clearly see a 4-cm adrenal mass. A large adrenal mass and acute heart and lung problems without other plausible explanations only point to one disease, pheo-induced cardiomyopathy and pulmonary edema. He should have been diagnosed earlier and been treated with alpha blockade and aggressive cardiac support with all available devices. Believe it or not, even the sickest patient with pheo-induced cardiomyopathy can survive with early diagnosis and appropriate treatment.

Dr. Pheo