Case Report: Atypical pheochromocytoma presenting with junctional rhythm tachycardia and troponin elevation

Background: Pheochromocytomas are rare neuroendocrine neoplasms with an annual incidence of at least 0.8 per 100,000 person-years and peak incidence between the 4th and 5th decade of life. These intraadrenal neoplasms hypersecrete catecholamines leading to aberrations in cardiovascular homeostasis, elevated sympathetic activity, and paroxysms of symptoms such as episodic headache, diaphoresis, tachycardia, and hypertension. Only one third of patients with pheochromocytoma present with classic symptoms, though a growing body of evidence has begun characterizing the atypical features of this disease. Here, we present one such case depicting the unusual presentation of a pheochromocytoma and atypical manifestations of this disease. Case Presentation: A 34-year-old Hispanic-American male presented to the emergency room with sole complaint of epigastric pain. Upon evaluation, ECG revealed the presence of junctional rhythm without ST changes, mildly elevated troponins, and high blood pressures, which was hypersensitive to nicardipine. This initial presentation was mired with discordant information which did not suggest a clear etiology. Upon further investigation, the patient reported a history of episodic shortness of breath, headache, and anxiety attacks which elucidated the clinical image and supported a presumptive suspicion of hypertension and early cardiomyopathy secondary to pheochromocytoma. After successful stabilization and discharge of the patient, 24-hour urine metanephrine results returned confirming elevated catecholamine breakdown products and the diagnosis of pheochromocytoma. The patient was informed of the gravity of his diagnosis and referred for outpatient surgical consult. Conclusion: This case demonstrates an atypical presentation of pheochromocytoma with cardiomyopathic features in a younger patient.