title: Recurrent takotsubo cardiomyopathy associated with pheochromocytoma.
abstract: OBJECTIVE
  To describe a case of recurrent takotsubo cardiomyopathy in a patient with pheochromocytoma.
  
  
  METHODS
  We present a case report, including clinical and laboratory data. In addition, the current relevant literature pertaining to pheochromocytoma and takotsubo syndrome is reviewed and summarized.
  
  
  RESULTS
  In 2004, an 81-year-old woman with no history of cardiac disease presented with chest discomfort, and takotsubo syndrome was diagnosed. No emotional or physical stressors were identified at that time. Her left ventricular systolic function normalized during that hospitalization. In 2007, the patient was readmitted to the hospital with chest discomfort and ST-segment elevation. Cardiac catheterization demonstrated only minor nonobstructive coronary artery disease. She was again found to have takotsubo syndrome with a classic apical hypokinetic segment. Treatment with a heart failure regimen was initiated, and she was screened for pheochromocytoma as the precipitant for her recurrent takotsubo cardiomyopathy. A 24-hour urine collection showed minimally elevated normetanephrine excretion of 719 microg (reference range, 148 to 560) and vanillylmandelic acid of 8.3 mg (reference range, <8.0). The plasma normetanephrine level was 1.57 pg/mL (reference range, <0.9). Subsequent magnetic resonance imaging revealed a left adrenal mass (2 cm by 1 cm). Ultimately, the patient underwent left adrenalectomy, and the pathology report was consistent with pheochromocytoma. She has been asymptomatic since then, and a repeated echocardiogram demonstrated normal left ventricular systolic function.
  
  
  CONCLUSIONS
  In patients presenting with takotsubo cardiomyopathy, a precipitating factor, such as emotional or physical stress, can often be identified. In some patients (such as our current case), however, pheochromocytoma may be the underlying disease and should be considered.
authors.affiliation: Department of Internal Medicine, Maine Medical Center, Portland, Maine, USA.
authors.forename: Ana P
authors.initials: AP
authors.lastname: Rossi
authors.forename: Robert G
authors.initials: RG
authors.lastname: Bing-You
authors.forename: Lisa R
authors.initials: LR
authors.lastname: Thomas
mesh_terms: D000310:Adrenal Gland Neoplasms / Q000097:blood / Q000150:complications* / Q000601:surgery; D000369:Aged, 80 and over; D002637:Chest Pain / Q000209:etiology; D005260:Female; D006801:Humans; D009647:Normetanephrine / Q000097:blood / Q000652:urine; D010673:Pheochromocytoma / Q000097:blood / Q000150:complications* / Q000601:surgery; D054549:Takotsubo Cardiomyopathy / Q000097:blood / Q000209:etiology*
chemical_list: D009647:Normetanephrine