“Heart” to Stomach the Headaches

1Hofstra North Shore-LIJ School of Medicine, Manhasset, NY

Meeting: Hospital Medicine 2015, March 29-April 1, National Harbor, Md.

Abstract number: 652

Keywords:

Case Presentation: 39 year old man with a PMH of testicular seminoma s/p orchiectomy presents with intermittent, sharp, left-sided abdominal pain in the subcostal region with radiation to the left flank and back of 2 weeks. On the night of admission the pain persists with associated symptoms of shortness of breath, chest discomfort, nausea and emesis. Of note, he endorsed symptoms of palpitations and headache in the past. Whenever he thought he was going to have a headache, he felt “it went to his stomach.” The patient appeared uncomfortable secondary to pain. He was afebrile, tachycardic and hypertensive. His physical exam was only notable for tenderness in the left upper quadrant of the abdomen. Labs were notable for leukocytosis with neutrophil predominance, hypokalemia, hyperglycemia, and an elevated lactate. EKG is notable for ST elevation in V1-V2 with reciprocal changes in the inferior leads. Left heart catherization revealed clean coronaries. TTE revealed hypokinesis of the anterolateral wall severe LVSD with EF of 25%. Despite cardiac symptoms, his workup is negative for an acute cardiac etiology. CT of abdomen/pelvis was obtained given abdominal pain and concern for infection: revealed a left adrenal mass suspicious for hemorrhage and suspicious for pheochromocytoma. Further serologies gathered were significant for elevated metanephrine and normetanephrine. Urine metanphrine and VMA were also elevated. The patient’s serologies were consistent with pheochromocytoma. Beta blockade use was held despite acute heart failure. During hospitalization course, the patient pressures normalized without intervention. Eventually, the patient was started on alpha-blocker. Upon stabilization patient was discharged to start a beta-blocker as an outpatient and to be further optimized for adrenal mass resection. 

Discussion: It is estimated the annual incidence of cathecholamine-secreting tumors is 2-8 per 1 million people. They are most common in the third to fifth decade and equally common in men and women. Pheochromocytoma has a classic triad of episodic headache, sweating, and tachycardia. Rarely, as in this person’s case, pheochromocytoma is associated with cardiomyopathy attributed to catecholamine excess that is similar to stress-induced cardiomyopathy.  It is important to avoid beta-adrenergic blockade and initiate alpha blockade first. Wall motion abnormalities may improve with surgical or medical treatment of pheochromocytoma. As opposed to this patient, an increasing number of pheochromocytoma patients have no symptoms and are diagnosed via an adrenal incidentaloma. 

Conclusions: This case serves to remind that pheochromocytoma is a rare, catecholamine-secreting tumor that may precipitate life-threatening cardiac manifestations, most commonly hypertension.  Once suspicion and confirmation of this diagnosis, prompt treatment is indicated. The tumor is malignant in 10% of cases may be cured completely by surgical removal.

To cite this abstract:

Pershad V, Belletti L. “Heart” to Stomach the Headaches. Abstract published at Hospital Medicine 2015, March 29-April 1, National Harbor, Md. Abstract 652. Journal of Hospital Medicine. 2015; 10 (suppl 2). https://www.shmabstracts.com/abstract/heart-to-stomach-the-headaches/. Accessed July 20, 2019.

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