Cardiogenic shock triggered by phaeochromocytoma crisis after an oral glucose tolerance test: a case report

Abstract

Background: Phaeochromocytomas are rare catecholamine-producing tumours which typically present with comparatively benign symptoms such as headache, palpitations, sweating, hypertension, and insulin resistance. In rare cases, severe cardiac manifestations have been reported. We describe a patient who developed severe hypoglycaemia after an oral glucose tolerance test (OGTT), potentially triggering a phaeochromocytoma crisis and cardiogenic shock. To the best of our knowledge, only four other cases of hypoglycaemia after OGTT have been reported in patients with phaeochromocytoma, of which none developed a phaeochromocytoma crisis.

Case summary: A 53-year-old woman with hypertension, dyslipidaemia, and prediabetes presented to the Emergency Department with hypoxia, hyperglycaemia, lactic acidosis, severe left ventricular dysfunction, and pulmonary oedema followed by cardiogenic shock. Onset of symptoms was only few hours after an OGTT during which she had developed severe transient hypoglycaemia. Angiography was performed due to elevated troponin levels and showed a midventricular contraction pattern typical of takotsubo. This was subsequently confirmed by cardiac magnetic resonance imaging. The patient's condition improved during the first 36 h and she was discharged home on Day 7. A positive catecholamine test prompted readmission to the Endocrinology Unit, where computer tomography confirmed the diagnosis of phaeochromocytoma. An adrenalectomy was performed, and the diagnosis was verified histopathologically.

Discussion: The possibility of a phaeochromocytoma must be considered as a potential triggering factor in patients presenting with takotsubo cardiomyopathy, in particular, when blood glucose levels fluctuate between severe hypo- and hyperglycaemia.

Keywords: Acute pulmonary oedema; Case report; Hyperglycaemia; Hypoglycaemia; Oral glucose tolerance test; Phaeochromocytoma; Takotsubo cardiomyopathy.

Figure 1

The initial electrocardiogram showed sinus tachycardia without apparent signs of ischaemia even if baseline shifting made analysis of ST-segments somewhat difficult.

Figure 2

Right coronary artery (A) and left coronary artery (B), showing absence of coronary artery lesions.

Figure 3

Cardiac magnetic resonance imaging showing typical signs of midventricular takotsubo. (A–D) Four-chamber (long axis) slices. (A) Modified Look-Locker Inversion Recovery pre-contrast T1 map (normal pre-contrast T1 range for myocardium at 3 T: 1200–1400 ms). Basal and apical regions: 1400 ms. Midventricular regions ∼1600 ms. (B) Extracellular volume map (from pre- and post-contrast Modified Look-Locker Inversion Recovery T1-maps; normal range for myocardium 20–30%) demonstrates increased extracellular space in the midventricular regions (35%) and normal values in the apical and basal regions (26–30%). (C) Cine steady-state free precession image at end-systole with hypokinesia/akinesia in the midventricular region. (D) Phase-sensitive inversion recovery late gadolinium enhancement showing no focal scar. (E–H) Basal/midventricular short-axis slices. (E) Modified Look-Locker Inversion Recovery pre-contrast T1-map (normal pre-contrast T1 range at 3 T: 1200–1400 ms). Pink/yellow regions 1550 ms. (F) ECV map (normal range for myocardium 20–30%). Anterior and lateral regions: ∼35% and inferoseptal regions: 29%. (G) Cine SSFP image at end-systole with hypokinesia/akinesia. (H) PSIR LGE showing no focal scar. ECV, extracellular; LGE, late gadolinium enhancement; PSIR, phase sensitive inversion recovery; SSFP, steady-state free precession.

Figure 4

Computed tomography displaying abnormal contrast uptake within a left adrenal phaeochromocytoma.