2 Clinical Cases Analysis Of Pheochromocytoma With Special Cardiovascular Presentation

Objective : Pheochromocytoma is a rare secondary hypertension.There are a few pheochromocytoma with special features,and the state of the disease is critical and changeable.So it is easy to misdiagnosis.We analyzed retrospectively the clinical data of 2 patients of pheochromocytoma with special cardiovascular presentation to elucidate the mechanism of their special cardiovascular presentation and to explore how to identify the special features of pheochromocytoma early.Methods: Tow cases of pheochromocytoma with special cardiovascular presentation were recruited from January 2016 to June 2017 in Dalian Municipal Central Hospital affiliated to Dalian Medical University.The course of diagnosis and treatment was analyzed.The diagnosis and treatment of pheochromocytoma and the mechanism of its special cardiovascular manifestations were discussed in combination with the latest literature.Results :Case 1 is a middle aged woman,with no history of hypertension.A few months ago,she mainly presented repeated palpitations,shortness of breath,headache induced by activity or emotion,and such symptom lasted for a short time.After a rest,it can relieve.And her blood pressure was normal when she felt better.When the condition suddenly deteriorated,the main presentation was acute pulmonary edema and signs of shock,such as obvious hypotension,sitting breathing,coughing pink foam phlegm,being wet and cold all over the body.The lung had wet rale,and the CT indicated pulmonary edema.cardiac echocardiography showed normal cardiac structure and function.Coronary angiography and renal arteriography excluded coronary artery disease and renal artery stenosis.CT scan of adrenal gland showed that the right adrenal gland was occupied A 2.6x2.4x2.4cm tumor containing dark red sac fluid was removed from the right adrenal gland during the operation.The pathological diagnosis was:(right adrenal)pheochromocytoma.Follow-up half year later,patient had normal BP.Conclusion: A large number of catecholamine was released into blood after the rupture of pheochromocytoma,which lead to flash pulmonary edema and hypotension similar to shock.Case 2 is an elderly male,with a hypertension history of 10 years.He took regular medicines,did not achieve the BP goal.maybe blood pressure was not significantly high,he was not concerned.There are typical symptoms of angina pectoris in the half of the year.In the past 1 week,he had chest pain and the pain were aggravated at rest.Coronary angiography and PCI further confirmed the diagnosis of coronary artery disease-acute coronary syndromes-anterior descending artery stenosis.His chest pain disappeared after stent implantation.Several days after PCI,palpitation occurred frequently,but there was no chest pain.ECG examination showed paroxysmal ventricular tachycardia.The ventricular tachycardia did not accompanied with chest pain,changes of electrocardiogram(ECG)and elevated serum myocardial injury markers.The patients had low blood pressure,slow heart rate,decreased urine volume and prerenal renal dysfunction.A special clinical manifestation of abnormal elevated blood pressure during a ventricular tachycardia and a rapid decrease in blood pressure after termination of ventricular tachycardia was also recorded.The patient was not a single ACS and could not be explained by normal postmyocardial infarction ventricular tachycardia(VT).It should accord with the pathophysiological features and clinical manifestations of pheochromocytoma with ruptured hemorrhage.Adrenal contrast enhanced CT scan showed that the right adrenal gland was occupied.The medial density of occupying space was low.The patients were transferred to urology for operation.After half a year follow-up,with no anti-hypertensive drugs taken,the blood pressure of the patients was normal,and the renal function was completely recovered.Conclusion: The diagnosis of ACS "blocked" the doctor's thinking.After PCI.the patient sustained hypotension,and the heart rate was not proportional to blood pressure and stayed slow and the patient had mental retardation.These symptoms and signs that ACS could not explain were not further explored,and doctors only "indulged" in the diagnosis of ACS.The reason of ACS was not understood accurately.Clinicians should strictly conduct the follow-up on hypertension and screen secondary hypertension before they can diagnose pheochromocytoma.High attentions should be paid to the clinical manifestations of the rupture of pheochromocytoma.Conclusion:1.Pheochromocytoma is a rare secondary hypertension.When the patient presents persistent refractory hypertension with accelerated heart rate and sweating,which is due to excessive release of catecholamine,the diagnosis is easier,but there are a small number of pheochromocytoma which is special,rare and difficult to diagnose.In particular,when associating with other diseases,the diagnosis may be more confusing.Unusual cardiovascular manifestations of pheochromocytoma include hypotension "shock",malignant arrhythmias such as ventricular tachycardia,alternating hypotension with hypertension,Orthostatic hypotension,and acute pulmonary edema,etc.2.High attentions should be paid to persistent hypotension with intermittent paroxysmal hypertension,hypotension with slow heart rate,abnormal elevation of blood pressure during ventricular tachycardia and the unexplainable evolution of primary hypertension into persistent hypotension,which suggests the clinical manifestation of the rupture of pheochromocytoma.After the rupture of pheochromocytoma tumor,the transient release of catecholamine into the blood and subsequent persistent plasma low catecholamine states lead to these characteristic clinical manifestations.3.For pheochromocytoma,the positive rate of routine blood,urine catecholamine and its metabolites,especially VMA,may not be high.Blood and urine samples should be collected in time window: blood samples should be collected when the patient attacks,and urine samples should be collected 2-3 hours after onset.In addition,it should be pointed out that although the detection of catecholamine and its metabolites is helpful in diagnosis,it is not essential.Typical and characteristic clinical manifestations,combined with clear imaging,can also reliably diagnose pheochromocytoma.