Hellenic Society of Cardiology (2017) 58, 372e377
Available online at www.sciencedirect.com
ScienceDirect journal homepage: http://www.journals.elsevier.com/ hellenic-journal-of-cardiology/
CASE REPORT
An unusual case of pheochromocytoma mimicking both acute coronary syndrome and central nervous system infection. Case report and literature review Andreas Mitsis a,*, Christina Hadjilouka a, Maria Skarpari b, Michael Myrianthefs a a b
Cardiology Department, Larnaca General Hospital, Larnaca, Cyprus Department of Internal Medicine, Larnaca General Hospital, Larnaca, Cyprus
Received 25 November 2016; accepted 23 December 2016
Available online 17 January 2017
KEYWORDS Pheochromocytoma; Hypertensive crisis; Catecholamines; Troponin; Acute coronary syndrome
1. Case Report A 58-year-old woman presented to the emergency department with recurrent episodes of nausea and vomiting. The patient reported that the symptoms had started two days prior. She denied any fever, chest pain, palpitations or shortness of breath but complained of a continuous headache. * Corresponding author. Dr. Andreas Mitsis, Cardiology and Aortic Centre, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, Sydney Street, London SW3 6NP, UK. Tel.: þ44 7387370772. E-mail addresses:
[email protected],
[email protected] (A. Mitsis). Peer review under responsibility of Hellenic Society of Cardiology.
With regard to cardiovascular risk factors, she was a heavy smoker (2 p/p/day for 20 years), although her family history was free of cardiovascular disease. Her past medical history was also unremarkable, except for a hysterectomy two years prior. At the time of admission, the patient had an acute hypertensive crisis with an elevated blood pressure of 210/ 104 mmHg. She was afebrile, had sinus tachycardia with a pulse of 120 beats/minute, a respiratory rate of 14 breaths/ minute and oxygen saturation on pulse oximetry of 98% on room air. The patient was anxious, with facial flushing, cold extremities and profuse sweating. The cardiovascular exam was benign. Her breath sounds were normal and the heart sounds were regular, with no murmur. The pulmonary exam also revealed normal breath sounds bilaterally. The abdominal exam was benign, with no masses appreciated. The neurological examination was
http://dx.doi.org/10.1016/j.hjc.2016.12.008 1109-9666/ª 2017 Hellenic Society of Cardiology. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Case report and literature review within normal limits, with no neurological defects. Her sensation was intact. A brain computed tomography (CT) scan was normal without evidence of ischemia, subarachnoid hemorrhage or mass. The electrocardiogram showed sinus tachycardia and ST and T wave changes consistent with left ventricular hypertrophy and/or anterolateral ischemia were noted [Fig. 1]. The chest radiograph (CXR) was within normal limits without evidence of respiratory disease. Transthoracic echocardiography revealed mild concentric left ventricular hypertrophy with normal overall systolic function and no regional wall motion abnormalities. Type 1 diastolic abnormality (abnormal relaxation pattern) and mild mitral regurgitation were also noted. Laboratory results were as follows. The white blood cell count (WBC) was 26450/mL with 88% neutrophils and 4.5% monocytes. The serum creatinine level was normal, and serum electrolytes were also normal with the exception of a low potassium (2.75 mmol/L). Serum glutamic oxalacetic transaminase and alkaline phosphatase levels were within normal limits. The fasting blood sugar level was 199 mg/dl and the C ereactive protein was increased (64 mg/L). The creatine kinase (CPK) was slightly elevated and so was the CK-MB isoenzyme (279 and 30.2 U/L, respectively). The cardiac troponin TnI was elevated (0.14 mg/L, normal range
