Emerging acute unilateral pulmonary edema in a patient with pheochromocytoma

Emerging acute unilateral pulmonary edema in a patient with pheochromocytoma

International Journal of Cardiology 133 (2009) e50 – e51 www.elsevier.com/locate/ijcard Letter to the Editor Emerging acute unilateral pulmonary ede...

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International Journal of Cardiology 133 (2009) e50 – e51 www.elsevier.com/locate/ijcard

Letter to the Editor

Emerging acute unilateral pulmonary edema in a patient with pheochromocytoma Itsuko Miyazawa a , Atsuyuki Wada a , Toshiro Sugimoto a,⁎, Norihisa Nitta b , Minoru Horie b a

Department of Internal Medicine, Shiga University of Medical Science, Japan b Department of Radiology, Shiga University of Medical Science, Japan

Received 23 August 2007; received in revised form 14 November 2007; accepted 16 November 2007 Available online 8 January 2008

Abstract We report a patient who presented with unilateral pulmonary edema without cardiomegaly. Our patient was finally diagnosed as having pheochromocytoma crisis. © 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Catecholamine; Pheochromocytoma; Pulmonary edema

1. Case report An 18-year-old woman was admitted because of dyspnea. The chest X-ray showed no cardiomegaly but showed acute pulmonary edema in the right lung field (Fig. 1). Chest computed tomography (CT) obtained at the level of aortic arch and orifice of inferior pulmonary vein shows ground-glass opacity, interlobular septal thickening, intralobular fine reticular opacity and consolidation in the right lung field (Fig. 2). Her echocardiogram showed left ventricular size and no significant valvular abnormalities, but left ventricular dysfunction, ejection fraction of 34%. Abdominal CT showed a mass of about 3.5 cm in the region of the left adrenal gland, the inside of which was cystic (Fig. 3). The serum and urine catecholamine levels were remarkably elevated; thus, the diagnosis of pheochromocytoma was made and the therapy of α/β antagonists was initiated, resulting in the improvement of cardiac function and lung congestion. The left adrenal

⁎ Corresponding author. The Department of Internal Medicine, Shiga University of Medical Science, Seta, Otsu, Shiga, 5202192, Japan. Tel.: +81 77 548 2222; fax: +81 77 543 3858. E-mail address: [email protected] (T. Sugimoto). 0167-5273/$ - see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2007.11.008

Fig. 1. The chest X-ray shows unilateral pulmonary edema without cardiac enlargement.

I. Miyazawa et al. / International Journal of Cardiology 133 (2009) e50–e51

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gland was removed and pathologically proved pheochromocytoma with necrosis. 2. Discussion Pulmonary edema as emerging manifestation of pheochromocytoma is uncommon and usually rapidly fatal. Pulmonary edema, which is either cardiogenic [1] or noncardiogenic [2] in origin, can occur. In most patients with pheochromocytoma, pulmonary edema is thought to be cardiogenic in origin. As our patient presented with acute transient cardiac dysfunction due to catecholamine-induced cardiomyopathy, her pulmonary edema might have evoked by cardiogenic mechanisms [3]. However, our case presented with unilateral lung edema without prominent pulmonary vessels, pleural effusion, or cardiomegaly; thus, we speculate that non-cardiogenic mechanisms might also have contributed to the development of her pulmonary edema [4]. The pathogenesis of non-cardiogenic pulmonary edema in patients with pheochromocytoma includes some theories, i.e., catecholamine-induced postcapillary venoconstriction resulting in a rise in pulmonary-capillary hydrostatic pressure, increased alveolo-capillary permeability due to catecholamine, and the catecholamine-induced neutrophil accumulation in the lung [5]. Our case suggests that pheochromocytoma should be considered in any

Fig. 2. Chest CT obtained at the level of superior lobe and orifice of inferior pulmonary vein shows ground-glass opacity, interlobular septal thickening, intralobular fine reticular opacity and consolidation in the right lung field.

Fig. 3. Abdominal CT shows about 3.5 cm left adrenal mass with a cystic legion surrounded by an enhanced region (arrow).

patients presenting with unexplained acute pulmonary edema. References [1] Sardesai SH, Mourant AJ, Sivathandon Y, Farrow B, Gibbons DO. Pheochromocytoma and cathechilamine-induced cardiomyopathy presenting as heart failure. Br Heart J 1990;63:234–7. [2] Takeshita T, Shima H, Oishi S, Machida N, Uchiyama K. Noncardiogenic pulmonary edema as the first manifestation of pheochromocytoma: a case report. Radiat Med 2005;23:133–8. [3] Vahdat A, Vahdat O, Chandraratna PAN. Pheochromocytoma presenting as reversible acute cardiomyopathy. Int J Cardiology 2006;108:395–6. [4] Ketai LH, Godwin JD. A new view of pulmonary edema and acute respiratory distress syndrome. J Thorac Imaging 1998;13:147–71. [5] Kondo K, Yokoyama A, Nakajima M, Kohno N. Pulmonary edema in pheochromocytoma. Internal Med 2004;12:1101–2.