Cardiogenic shock in phaeochromocytoma multisystem crisis: a case report.

Background: Phaeochromocytoma multisystem crisis (PMC) is characterized by labile blood pressures (extremes of hypo- and/or hypertension) and multiorgan failure as a result of catecholamine excess. Initial stabilization requires pharmacological and/or mechanical circulatory support, followed by the institution of antihypertensives to correct the underlying pathophysiology. Case summary: A previously well 40-year-old male developed a sudden onset of breathlessness. On presentation, he was in shock with multiorgan failure. He required intubation, mechanical ventilation, dual inotropic support, and renal replacement therapy. Bedside echocardiogram showed a severely impaired left ventricular ejection fraction (LVEF) of 25%. Coronary angiography revealed normal coronary arteries. In view of raised inflammatory markers and transaminitis, a computed tomography abdomen/pelvis was performed. An incidental left adrenal mass was found. Further work-ups revealed raised plasma metanephrine and normetanephrine, 24-h urine epinephrine, and norepinephrine. A cardiac magnetic resonance (CMR) showed myocardial inflammation and reverse Takotsubo pattern of regional wall motion abnormality (RWMA). The diagnosis of cardiogenic shock and stress cardiomyopathy secondary to PMC was made. He was subsequently initiated on α- and ß-blockers and goal-directed medical therapy for heart failure. A 68Ga-DOTATATE scan showed avid tracer uptake of the left phaeochromocytoma. An interval CMR 3 weeks from presentation showed near normalization of the LVEF and RWMA. He underwent a successful laparoscopic left adrenalectomy and was antihypertensive-free since. Discussion: The clinical suspicion for PMC as the cause of cardiogenic shock requires astute clinical judgement, while the management requires an understanding of the underlying pathophysiology that calls for multidisciplinary inputs.

Pulmonary Mucoepidermoid Carcinoma With Multiple Paraneoplastic Syndromes.

Pulmonary mucoepidermoid carcinoma (PMEC) is rare and challenging to diagnose. Its association with paraneoplastic syndromes is poorly described. It is also uncommon for a patient with lung cancer to present with multiple paraneoplastic syndromes. We report a case of a patient with metastatic high-grade PMEC associated with three paraneoplastic syndromes, namely, humoral hypercalcemia of malignancy, ectopic ACTH syndrome, and paraneoplastic leukemoid reaction.

Pigmented epithelioid melanocytoma with nodal melanosis: A rare cause of cystic cervical lymphadenopathy.

BACKGROUND: Head and neck malignancies often present as firm, solid nodal masses. However, malignancies arising from Waldeyer's Ring may give rise to cystic lymph nodes. METHODS: A 57-year-old man was referred for left-sided neck swelling of 2 weeks' duration. A CT scan revealed an enlarged cystic cervical node at level 5A/B and he underwent excision biopsy. RESULTS: Histology reported nodal fibrosis with melanophages. Further examination revealed a black nodule on his back where he had wide excision and the histology confirmed pigmented epithelioid melanocytoma. CONCLUSION: Cervical lymphadenopathy can rarely be due to an upper back lesion, such as pigmented epithelioid melanocytoma. Thus, routine clinical examination of the upper back should be performed in patients with cervical lymphadenopathy.

Persistent hyperthyroidism and de novo Graves' ophthalmopathy after total thyroidectomy.

We report a patient with Graves' disease who remained persistently hyperthyroid after a total thyroidectomy and also developed de novo Graves' ophthalmopathy 5 months after surgery. She was subsequently found to have a mature cystic teratoma containing struma ovarii after undergoing a total hysterectomy and salpingo-oophorectomy for an incidental ovarian lesion. LEARNING POINTS: It is important to investigate for other causes of primary hyperthyroidism when thyrotoxicosis persists after total thyroidectomy.TSH receptor antibody may persist after total thyroidectomy and may potentially contribute to the development of de novo Graves' ophthalmopathy.