Ijaz Ahmad, Ramachandran Sankaran, Abdulrazak Al.
Rapid Reversal of Heart Failure in a Patient with Pheochromocytoma and Catecholamine-induced Myocarditis / Cardiomyopathy.
J Coll Physicians Surg Pak Jan ;12(9):562-4.

A previously fit asymptomatic 47-year-old male was admitted as an elective patient for excision of two small swellings in the right groin and back (proved to be epidermal cysts on histopathology). The pre-operative anesthetic assessment was unremarkable including 12- lead electrocardiogram (ECG). The patient received inhalation anesthesia via laryngeal mask and the surgical procedure was carried out. His vital signs were stable until end of the procedure when he developed a spike of hypertension, blood pressure (B.P) 180/110 increasing to 240/140. He received intravenous hydralazine, which failed to control hypertension in the next 15 minutes. The patient recovered following anesthesia but developed respiratory distress with foamy secretions, tachypnea and increasing difficulty in oxygenation suggestive of pulmonary edema. He was given high doses of intravenous frusemide and nitroglycerine to bring down the blood pressure and relieve florid pulmonary edema. Hypertensive crisis with underlying pheochromocytoma was suspected because the patient had been asymptomatic and normotensive prior to the event. The patient was intubated and transferred to intensive care unit for mechanical ventilation and hemodynamic monitoring. He developed marked hypotension and severe tissue hypo-perfusion with lactic acidosis and was anuric for several hours. Intravenous nitroglycerine was discontinued and he was started on dopamine and dobutamine at inotropic doses to maintain mean arterial pressure of 60 mmHg. Chest X-Ray revealed frank pulmonary edema with extensive alveolar consolidation and air bronchogram. A 12-lead ECG revealed marked sinus tachycardia without significant ischemic ST-T changes. Urgent bedside echocardiography was done which revealed normal sized cardiac chambers with severe global left ventricular hypokinesia. Left Ventricular End Diastolic Dimension (LVEDD)= 47 mm and Left Ventricular Systolic Dimension (LVSD)= 42 mm. Approximate left ventricular ejection fraction (EF) was 20-25%. Liver enzymes were grossly raised AST 420 U/L, ALT 287 U/L, Alk Phosphatase 121 U/L, and total bilirubin 33 micromol/L, consistent with the tissue under perfusion. His white cell count rose to 22.4x 109 /L. CPK peaked 10,000 U/L, CKMB 417 U/L, and LDH 1672 U/L consistent with very substantial myocardial necrosis. Blood sample was taken for plasma catecholamines levels which were: plasma noradrenaline= 1030 nmol/l (normal limit in adults is < 2.7nmol/l); plasma adrenaline = 880 nmol/l (normal < 0.7 nmol/l); plasma dopamine = 676 nmol/l (normal < 0.55 nmol/l). Urine was also collected for 24 hours, which revealed very high Vanillylmandelic Acid (VMA)-about three times upper limit of normal range. An echocardiogram was repeated on second and fourth day, which revealed same findings as on first day i.e normal sized LV with severe global hypokinesia with estimated left ventricular ejection fraction of less than 20%-25%. No segmental wall motion abnormality was seen; there was no pericardial effusion. Serial ECGs did not reveal significant ischemic ST-T changes. On fifth day of admission in ICU with stabilization of hemodynamic status, phenoxybenzamine and captopril were started and doses gradually increased. The patient continued to improve and on eighth day of admission he was extubated. Following extubation he exhibited signs of mild confusional state and intestinal pseudo-obstruction, which was managed conservatively. On eleventh day of admission in ICU, follow up echocardiogram showed almost complete recovery of global left ventricle (LV) systolic function with approximate EF =50-55%.

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