Recurrent Fulminant Myocarditis Revealing a Pheochromocytoma

Abstract

IntroductionAcute myocarditis is commonly induced by various infections, toxins, drug reactions and autoimmune diseases. Pheochromocytoma is a rare but curable etiology. The diagnosis of pheochromocytoma, called the "great imitator", is definitely one of the most challenging given its wide range of presentations. Making this diagnosis can in fact avoid potentially fatal complications. We report the case of a 61-yearold woman in whom the recurrence of fulminant myocarditis revealed a pheochromocytoma. Case ReportA 61-year-old woman was referred to our center on April 2009 for acute chest pain suggestive of angina. Her previous medical history was significant for type 2 diabetes and systemic hypertension evolving since 2007. She reported flu-like syndrome 15 days before the onset of current symptoms. Electrocardiogram (ECG) at presentation revealed 2 mm ST-segment depression in inferior, apical and lateral leads and premature ventricular beats (Figure 1). Troponin and Creatin-Phospho-Kinase Levels (CPK) were increased and amounted respectively to 23 ng/ml and 495 UI/l. C-reactive protein (CRP) level was inferior to 5 mg/l. Coronary angiography performed at the seventh hour of onset of symptoms showed normal and patent coronary arteries. We did not perform left ventriculography because of high left ventricular end-diastolic pressure (20 mmHg). One hour later, our patient presented rapid deterioration of both hemodynamic and respiratory status justifying her referral to intensive care unit. Cardiogenic shock was confirmed by hemodynamic study performed in the resuscitation department by PiCCO ® monitoring. She received Dobutamine and Furosemide and underwent non-invasive ventilation. Trans-thoracic echocardiography (TTE) performed on the first day (under Dobutamine 10 µg/kg/min) has shown impaired left ventricular systolic function (left ventricular ejection fraction (LVEF)=45%), diffuse hypokinesis, and a moderate functional mitral regurgitation (MR). Clinical course was favorable; Furosemide and Dobutamine were respectively withdrawn on the second and fifth day of hospital stay. Fulminant myocarditis was strongly suspected even if cardiac Abstract Introduction: Pheochromocytoma is a rare etiology of fulminant myocarditis. It is however a curable tumor in which surgical ablation spares patients from dreadful cardiac complications.