You’ll test scads of patients for pheochromocytoma who don’t have the disease. If you finally do encounter it the textbook features you’ve been taught may be buried in a morass confusing findings and mimics.
The patient presented with a picture of cardiogenic shock and elevated cardiac markers. Although there was myocardial damage it wasn’t a territorial myocardial infarction due to coronary artery disease. One red flag against the diagnosis of classical myocardial infarction was the presence of cardiogenic shock and a profound drop in the ejection fraction despite only a mild troponin leak. Something else was going on. Although the article didn’t mention this red flag it did provide a nice discussion on the differential diagnosis of troponin elevation due to conditions other than classical myocardial infarction.
Buried in this constellation of findings was the triad we were all taught: headache, palpitation and diaphoresis. The authors noted:
Headache, palpitations, and diaphoresis are the most frequent symptoms of pheochromocytoma. If all 3 present together, the specificity of this combination of symptoms for the diagnosis of pheochromocytoma is greater than 90%.
Pretty astounding given the ubiquity of those symptoms.
Perhaps more telling was the patient’s left ventriculogram, which showed a markedly reduced ejection fraction and mid ventricular ballooning closely resembling the left ventriculograms in this series of patients with Takotsubo cardiomyopathy. Pheochromocytoma cardiomyopathy is physiologically similar to Takotsubo cardiomyopathy. I suspect that had this patient had a myocardial biopsy it would have shown contraction band necrosis.
Speaking of Takotsubo cardiomyopathy---will we see a spike following the Wall Street meltdown?