Fulminant pheochromocytoma crisis triggered by glucocorticoids: ultra-early adrenalectomy under ECMELLA support

Pheochromocytoma crisis is a rare but life-threatening condition that may present with refractory cardiogenic shock and malignant arrhythmias. In this setting, the patient is often too unstable for surgery, although tumor removal remains the only definitive treatment. We report the case of a 57-year-old woman with an adrenal mass who developed a fulminant catecholaminergic crisis after high-dose glucocorticoid administration for contrast allergy prophylaxis. She presented with severe metabolic acidosis (pH 6.98, lactate 14.8 mmol/L), flash pulmonary edema, and acute catecholamine-induced cardiomyopathy with a Takotsubo pattern (LVEF 25%). Initial support with Impella CP was insufficient due to electrical storm and hypermetabolic state. Mechanical support was escalated to combined veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and Impella (ECMELLA). Because of persistent instability, ultra-early robot-assisted adrenalectomy was performed under full mechanical support. The patient was successfully weaned from Impella on postoperative day (POD) 1 and from ECMO on POD5, with progressive cardiac recovery (LVEF 35% at POD14). To our knowledge, this is one of the first (or the first) reported cases of robot-assisted adrenalectomy performed under full ECMELLA support without prior durable hemodynamic stabilization, suggesting a potential role for this strategy in highly selected patients with refractory pheochromocytoma crisis. It also underscores glucocorticoids as a critical and underrecognized trigger.