title: Endomyocardial biopsy in a patient with hemorrhagic pheochromocytoma presenting as inverted Takotsubo cardiomyopathy.
abstract: A 29-year-old female patient presented with shock and dyspnea due to heart failure and pulmonary edema. Echocardiography indicated excessive contraction limited to the left ventricular apex and akinesis of the basal and middle ventricle, which were confirmed by emergency left ventriculography. The finding was diagnostic of inverted Takotsubo cardiomyopathy. An abdominal computed tomography scan showed a tumor in the left adrenal gland with a central low-density area, and the plasma and urinary catecholamines were strikingly elevated. Taken together, these findings suggested the presence of a hemorrhagic pheochromocytoma. A myocardial biopsy in the very acute stage on the day of admission revealed neutrophilic infiltration and contraction-band necrosis, which was indistinguishable from the previously reported pathology in the acute phase of idiopathic Takotsubo cardiomyopathy without pheochromocytoma. The diagnosis of pheochromocytoma in this case was confirmed 7 weeks later by surgical removal of the left adrenal gland with massive hemorrhage at the center of the pheochromocytoma. The marked similarity of the endomyocardial pathology between this case and cases with idiopathic Takotsubo cardiomyopathy strongly points to catecholamine excess as a common causality for Takotsubo cardiomyopathy with or without pheochromocytoma.
authors.affiliation: Department of Cardiology, Aizawa Hospital, 2-5-1 Honjou, Matsumoto, Nagano, 390-8510, Japan. k_110@cc.hirosaki-u.ac.jp
authors.forename: Kohei
authors.initials: K
authors.lastname: Iio
authors.forename: Shunpei
authors.initials: S
authors.lastname: Sakurai
authors.forename: Tamon
authors.initials: T
authors.lastname: Kato
authors.forename: Shigeki
authors.initials: S
authors.lastname: Nishiyama
authors.forename: Takeki
authors.initials: T
authors.lastname: Hata
authors.forename: Eiichiro
authors.initials: E
authors.lastname: Mawatari
authors.forename: Chihiro
authors.initials: C
authors.lastname: Suzuki
authors.forename: Kazuhiro
authors.initials: K
authors.lastname: Takekoshi
authors.forename: Kayoko
authors.initials: K
authors.lastname: Higuchi
authors.forename: Toru
authors.initials: T
authors.lastname: Aizawa
authors.forename: Uichi
authors.initials: U
authors.lastname: Ikeda
mesh_terms: D000310:Adrenal Gland Neoplasms / Q000150:complications* / Q000175:diagnosis / Q000601:surgery; D000315:Adrenalectomy; D000328:Adult; D015415:Biomarkers / Q000097:blood / Q000652:urine; D001706:Biopsy; D002395:Catecholamines / Q000097:blood / Q000652:urine; D004452:Echocardiography; D004562:Electrocardiography; D004699:Endocardium / Q000473:pathology*; D005260:Female; D006470:Hemorrhage / Q000209:etiology*; D006801:Humans; D008279:Magnetic Resonance Imaging; D009206:Myocardium / Q000473:pathology*; D009336:Necrosis; D020556:Neutrophil Infiltration; D010673:Pheochromocytoma / Q000150:complications* / Q000175:diagnosis / Q000601:surgery; D011237:Predictive Value of Tests; D011654:Pulmonary Edema / Q000209:etiology; D012770:Shock, Cardiogenic / Q000209:etiology; D054549:Takotsubo Cardiomyopathy / Q000209:etiology* / Q000473:pathology; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
chemical_list: D015415:Biomarkers; D002395:Catecholamines