Takotsubo syndrome induced by malignant pheochromocytoma in a patient with type 2 papillary renal cell carcinoma - a case report

Abstract

The clinical presentation of the Takotsubo syndrome mimics an acute coronary syndrome with chest pain, ischemia-like ECG changes, mild to moderate myocardial enzyme elevation, and apical ballooning on echocardiography and ventriculography. On coronary angiography, epicardial coronary arteries are either normal or exhibit minimal atherosclerotic changes. Primary Takotsubo syndrome usually occurs in postmenopausal women in whom symptoms are triggered by emotional or physical stress, associated with catecholamine surges. Secondary Takotsubo syndrome may have multiple causes, including an increased catecholamine release due to pheochromocytoma. We present the case of a 56-years-old woman with confirmed Takotsubo syndrome who was later diagnosed with pheochromocytoma and type 2 papillary renal cell carcinoma.

Keywords: Takotsubo syndrome; malignant pheochromocytoma; papillary renal cell carcinoma.

Figure 1

12-lead electrocardiogram – sinus rhythm, heart rate 72 beats/minute, QRS axis +15°, ST segment elevation in V1–V6, D I and aVL.

Figure 2

Echocardiogram – apical 4 chamber view showing apical ballooning.

Figure 3

Contrast-enhanced CT – Figure 3A. Axial view: suprarenal, irregularly shaped tumor, 8.7/12.7/12.0 cm, with heterogeneous aspect, central necrosis, and infracentimetric calcifications; the mass invades the left renal vena cava by a tumoral thrombus, 7.3 cm long, extending to the origin of the inferior vena cava, and displaces the splenic vein anteriorly, without impeding the flow. Collateral circulation is visible around the mass. Figure 3B. Axial view: The left kidney is enlarged due to two simple cortical cysts (inferior pole) and a medio-renal natively hypodense lesion of 2.7/4.2/3.7 cm, with heterogeneous contrast enhancement, suggesting a Bosniak III renal cyst.