A Case of Pheochromocytoma-induced Reverse Tako-Tsubo Cardiomyopathy: Insights from Multimodal Imaging

Jeong, Jun-Chang; Choi, Kang-Un; Jeong, Jun-Chang; Choi, Kang-Un

Clin Ultrasound > Accepted Articles

Jun-Chang Jeong¹

, Kang-Un Choi²

¹Department of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Daegu, Korea
²Division of Cardiology, Yeungnam University Medical Center, Daegu, Korea

Address for Correspondence:

Kang-Un Choi ,Tel: 82-53-620-3313, Fax: 82-53-620-3313, Email: tipcode@gmail.com

Received: 17 March 2025; Accepted: 21 March 2025. Published online: 21 March 2025.

ABSTRACT

A 50-year-old female with pheochromocytoma presented with squeezing chest pain, palpitations, and high blood pressure. Laboratory results showed creatine kinase-MB 5.0 ng/mL, high-sensitivity troponin I (hsTnI) 0.954 ng/mL, and N-terminal pro-B type natriuretic peptide 238 pg/mL. Transthoracic echocardiography (TTE) revealed a left ventricular ejection fraction (LVEF) of 48% and regional wall motion abnormalities (RWMA) consistent with the reverse Tako-Tsubo pattern. Coronary angiography showed no stenosis, and an ergonovine provocation test was negative. Supportive care resolved symptoms, and hsTnI levels normalized. Cardiac fludeoxyglucose-18 (FDG) positron emission tomography (PET)/magnetic resonance (MR) confirmed stress cardiomyopathy (SCMP) with myocardial edema. One month earlier, catecholamine levels were elevated, with 24-hour urine metanephrine >7.50 mg/day and vanillylmandelic acid >15.48 mg/day. Whole-body PET/computer tomography (CT) revealed a 3.8 cm left adrenal mass with increased FDG uptake, consistent with pheochromocytoma. Abdominal CT confirmed a 3.4 × 3.8 cm adrenal mass. Follow-up TTE after 2 days showed full recovery of RWMA and LVEF. SCMP, triggered by catecholamine surges, presents with reversible LVEF reduction and RWMA unrelated to coronary territory. Pheochromocytoma, a catecholamine-producing tumor, can cause SICMP. Typical echocardiographic findings include the Tako-Tsubo pattern (apical ballooning). However, an atypical form, reverse Tako-Tsubo, involves basal hypokinesis with apical sparing. This case highlights the role of pheochromocytoma in SCMP, diagnosed via TTE and cardiac PET/MR. Recognizing reverse Tako-Tsubo in SCMP is crucial for early diagnosis and management.

Keywords: Stress Cardiomyopathy; Pheochromocytoma; PET Imaging