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Title:(Do not enter author details)
Heartbroken? A Thirty Year Old Woman with Rapidly Progressive Multi-organ Failure and Shock
Case description: (Your textmust use Normal style and mustfit into the box. Do not enter author details)
A 30 year-old woman who was previously healthy presented to the hospital with depression, anorexia, and “little energy” which had started over the previous month. She had attributed these symptoms to a stressful break-up with her boyfriend of several years. In the prior week, she had also developed diffuse abdominal pain, nausea, vomiting, diarrhea, and chills. On the morning of her arrival at the hospital, she became acutely dyspneic and weak, activated EMS, and was taken to a local hospital. On arrival, her initial vital signs were heart rate 130 beats/min, BP 60/40 mmHg, and oxygen saturation of 79% on room air. Physical exam was remarkable for a cool and clammy young woman, unresponsive to stimuli, with jugular venous distension, decreased breath sounds at lung bases, tachycardia with nl S1, S2, normal abdominal exam, and no peripheral edema. She was emergently intubated and started on norepinephrine, vasopressin, and neosynephrine and multiple liters of intravenous normal saline. Laboratory work was significant for WBC 38,000, BUN 31 mg/dL, Creatinine 3.6 mg/dL, amylase 630, lipase 170, AST 560, ALT 312, troponin positive at 13.82. She had normal thyroid function, blood alcohol level negative, urine toxicology negative, pregnancy test negative, preliminary urine cultures negative. She was anuric. She was started on stress dose steroids and activated protein C for suspected septic shock and multisystem organ failure. Electrocardiogram demonstrated sinus tachycardia with diffuse T wave flattening. CT Chest demonstrated small consolidating infiltrates at both lung bases that were consistent with severe pneumonia, pulmonary hemorrhage, septic emboli, or metastatic disease. CT Abdomen and Pelvis demonstrated no pancreatitis and incidental adrenal mass. Echocardiogram demonstrated severe global LV systolic dysfunction with an ejection fraction of 10-15%. All blood and urine cultures were negative.
Diagnosis: (Your textmust use Normal style and mustfit into the box)
‘Given adrenal mass, we sent urine and plasma metanephrines, which were both elevated. We initiated dialysis. We started her on digoxin and ionotropes, and were able to wean her off pressor medications. We later began beta blockade and alpha blockade with rapid improvement in her symptoms. MRI abdomen demonstrated heterogenous adrenal mass with hemorrhage, worrisome for pheochromocytoma – no evidence of metastatic disease was noted. A pheochromocytoma was removed several weeks later by General Surgery. Repeat echocardiogram done 4 months later demonstrated normal LV function. Conclusion: Idiopathic dilated cardiomyopathy as a rare presentation of pheochromocytoma.