Cheng Han, Gu Ling-Tong, Yang Jing
Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China.
World J Cardiol. 2025 Aug 26;17(8):110366. doi: 10.4330/wjc.v17.i8.110366.
Pheochromocytoma, a rare catecholamine-secreting tumor, typically presents with the classic triad of headache, palpitations, and diaphoresis, often accompanied by cardiovascular manifestations. While vomiting occurs in approximately 34.5% of cases, it is rarely the predominant and persistent presenting symptom. Pheochromocytoma-induced cardiomyopathy leading to heart failure is a recognized but uncommon complication. Due to its heterogeneous presentations, misdiagnosis and diagnostic delay are frequent.
A 53-year-old female presented predominantly with persistent and refractory vomiting as her chief complaint, accompanied by signs of acute heart failure [left ventricular ejection fraction (LVEF) 30%]. Initial evaluation at a primary hospital, including coronary angiography (revealing only mild stenosis), led to a misdiagnosis of coronary artery disease. Despite standard anti-thrombotic, anti-heart failure, and anti-emetic therapy, her vomiting persisted and heart failure did not resolve. Subsequent hospitalization revealed dramatic paroxysmal hypertension (202/129 mmHg to 97/51 mmHg) and fever. Significantly elevated plasma metanephrines and normetanephrine, combined with abdominal computed tomography and magnetic resonance imaging, confirmed a right adrenal pheochromocytoma. This diagnosis was significantly delayed due to the atypical prominence of gastrointestinal symptoms masking the underlying endocrine crisis.
This case highlights a highly atypical presentation of pheochromocytoma dominated by refractory vomiting and complicated by acute catecholamine-induced cardiomyopathy. It emphatically underscores that pheochromocytoma must be considered in the differential diagnosis for patients presenting with unexplained, treatment-resistant vomiting, particularly when co-existing with acute heart failure. The presence of labile hypertension, even if not initially evident, provides a crucial diagnostic clue. Prompt biochemical screening (catecholamine metabolites) and adrenal imaging are essential to prevent diagnostic delay and enable timely, life-saving surgical intervention.
嗜铬细胞瘤是一种罕见的分泌儿茶酚胺的肿瘤，通常表现为头痛、心悸和多汗的典型三联征，常伴有心血管表现。虽然约34.5%的病例会出现呕吐，但它很少是主要的持续性症状。嗜铬细胞瘤诱发的心肌病导致心力衰竭是一种已被认识但不常见的并发症。由于其表现多样，误诊和诊断延迟很常见。
一名53岁女性以持续性难治性呕吐为主诉就诊，伴有急性心力衰竭体征[左心室射血分数（LVEF）30%]。在一家基层医院的初步评估，包括冠状动脉造影（仅显示轻度狭窄），导致误诊为冠状动脉疾病。尽管进行了标准的抗血栓、抗心力衰竭和止吐治疗，她的呕吐仍持续存在，心力衰竭也未缓解。随后住院检查发现有剧烈的阵发性高血压（202/129 mmHg至97/51 mmHg）和发热。血浆间甲肾上腺素和去甲间甲肾上腺素显著升高，结合腹部计算机断层扫描和磁共振成像，确诊为右肾上腺嗜铬细胞瘤。由于胃肠道症状的非典型突出掩盖了潜在的内分泌危机，该诊断被显著延迟。
本病例突出了嗜铬细胞瘤一种高度非典型的表现，以难治性呕吐为主，并伴有急性儿茶酚胺诱发的心肌病。它着重强调，对于出现无法解释的、治疗抵抗性呕吐的患者，尤其是伴有急性心力衰竭时，鉴别诊断中必须考虑嗜铬细胞瘤。即使最初不明显，不稳定高血压的存在也提供了关键的诊断线索。及时进行生化筛查（儿茶酚胺代谢产物）和肾上腺成像对于防止诊断延迟以及进行及时的、挽救生命的手术干预至关重要。
