Reverse Takotsubo Pattern in the Setting of Undiagnosed Pheochromocytoma and Pulmonary Embolism: A Rare Presentation

BACKGROUND Takotsubo cardiomyopathy is a rare acute cardiac event with varied manifestations characterized by abrupt onset of transient regional dysfunction in a characteristic pattern. A reverse Takotsubo pattern is also well recognized but can also be seen in non-Takotsubo cardiomyopathies. CASE REPORT A 23-year-old woman with history of migraines and palpitations presented with nausea, vomiting, pleuritic chest pain, and dyspnea. On initial presentation her vitals were stable and her physical exam was unremarkable. Lab test results were significant for an elevated troponin and D-dimer. An initial CXR was unremarkable. The differential was concerning for pulmonary embolism. Prior to getting a CTA to establish diagnosis, she quickly decompensated. She was emergently intubated due to hypoxia and altered mental status. A repeat CXR showed acute pulmonary edema and repeat lab work showed increasing troponin and creatinine. EKG showed lateral ST depressions the lateral leads and ST elevations in aVL. ECHO showed akinesia of ½ to 2/3rd of proximal LV with a hyperdynamic functioning distal 1/3 LV and an estimated LVEF of 31%, a pattern consistent with reverse Takotsubo. She quickly developed multi-organ failure and, despite aggressive measures, underwent a PEA arrest and was unable to be successfully resuscitated. The autopsy showed hemorrhagic rupture of pheochromocytoma and bilateral thromboemboli of the main pulmonary arteries. CONCLUSIONS Reverse Takotsubo variant pattern can be seen in non-Takotsubo cardiomyopathies, and in our patient was noted in the presence of pheochromocytoma and pulmonary embolism. In this scenario, the presence of both would have significantly affected management, if she had not decompensated so quickly.