Internal Medicine Resident PGY2 Baylor Scott & White Temple Baylor Scott & White Temple Belton, Texas, United States
Disclosure(s):
Camron Costa, MD: No financial relationships to disclose
Background: Pheochromocytoma crisis (PC) is a rare endocrine emergency associated with significant mortality that can occur spontaneously or be precipitated by trauma, medications, or stress. We present a PC case in the setting of presumed Streptococcal pharyngitis, steroid administration, and refractory shock requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO) and Impella support.
Methods: A 31 year old female presented to an outside urgent care with malaise, sore throat, and shortness of breath. Patient diagnosed with presumed streptococcal pharyngitis vs COVID-19 infection, as this occurred at the initial wave of the COVID-19 pandemic. She received antibiotics and decadron with interval improvement. She later re-presented with acute respiratory failure. She was noted to be tachycardic in the 180s, febrile at 102 degrees Fahrenheit, and required emergent intubation. Initial blood pressure 110/60 with progressive decline. Troponin was elevated and peaked at 77.63, BNP 184, and lactic acid of 10.5. Echocardiogram demonstrated severely reduced left ventricular systolic function with an ejection fraction of 10%. Chest Xray and CT chest demonstrated bilateral pulmonary infiltrates as well as an adrenal mass. Given continued decline, rapid escalation in vasopressor requirements as well as refractory hypoxia, she was placed on VA-ECMO and Impella CP for left ventricular unloading. Left heart catheterization with normal anatomy and flow. Given recent steroid administration and adrenal mass on imaging, concern for PC. Patient was weaned from VA-ECMO support and with multidisciplinary team approach involving Cardiothoracic surgery, Endocrine surgery, Cardiology and Pulmonary Critical care, patient underwent Impella 5.5 supported adrenalectomy with pheochromocytoma confirmed on pathology.
Outcome: Over the course of eight days during her hospitalization, circulatory and vasoactive support were able to be weaned off and her left ventricular ejection fraction quickly improved from 10% to 60% prior to discharge. At 6 months, Cardiac MRI demonstrated normal myocardium and normal systolic function.
Conclusion: We discuss a rare occurrence of PC following steroid administration with resulting progressive shock requiring VA-ECMO and left ventricular unloading with Impella.
