Complex Presentation of Pheochromocytoma: Hypertensive Encephalopathy and Takotsubo-Like Cardiomyopathy in a Young Female

Challenging differential diagnosis Background:Pheochromocytoma, a rare catecholamine-secreting tumor, often presents with paroxysmal or sustained hypertension, tachycardia, headache, and diaphoresis.Timely diagnosis is essential to prevent adverse complications.Less common presentations include pheochromocytoma crisis, with severe neurological and cardiac complications. Case Report:We report a unique case of a 25-year-old woman who initially presented with pheochromocytoma-induced hypertensive encephalopathy and acute coronary syndrome.Echocardiography revealed takotsubo-like cardiomyopathy, and magnetic resonance imaging of the brain revealed posterior reversible encephalopathy syndrome.Initial treatment focused on controlling her blood pressure and supporting cardiac function.Due to her recovering from immediate crisis and absence of further symptoms, the patient refused further follow-up.However, she eventually experienced another episode of hypertensive crisis 2 years later.Subsequent investigations with 24-h urine tests revealed elevated vanillylmandelic acid levels (7.93 mg/24 h), normetanephrine (2638.72 µg/24 h), and nor-metanephrine to creatinine ratio (3546.67)and normal urine metanephrine levels (195.92µg/24 h) and metanephrine to creatinine ratio (263.33).Contrast-enhanced computed tomography of the abdomen revealed a 4.3×3.1×4-cmmass in the right adrenal gland.A DOTATATE positron emission tomography scan revealed a 3.9×4.3×2.7-cmlocalized right adrenal pheochromocytoma.Biochemical testing and adrenal imaging revealed a previously undiagnosed pheochromocytoma.Following targeted medical therapy and right adrenalectomy, the patient achieved complete resolution of her hypertension and associated symptoms. Conclusions:Our case is a unique simultaneous presentation of posterior reversible encephalopathy syndrome and takotsubo-like cardiomyopathy, highlighting the importance to consider pheochromocytoma in acute neurological and cardiac presentations, even in the absence of typical symptoms.