Resolution of reverse takotsubo cardiomyopathy secondary to presumed pheochromocytoma with intralesional hemorrhage

A 38-year-old woman with a history of migraine headaches presented with episodic headaches, palpitations, chest pain, and worsening dyspnea. On arrival, she was hypertensive and tachycardic. Electrocardiography demonstrated inferolateral ST-segment depressions, QT interval prolongation, and elevated troponin levels, raising concern for acute myocardial infarction. Emergent coronary angiography revealed normal coronary arteries, while left ventriculography demonstrated basal hypokinesis with apical hyperkinesis, consistent with reverse takotsubo cardiomyopathy. Abdominal computed tomography identified a 3 cm right adrenal nodule, and 24-hour urine metanephrine levels were elevated to >8× the upper limit of normal, suggestive of pheochromocytoma. The patient was managed conservatively with alpha-adrenergic blockade. Follow-up abdominal magnetic resonance imaging demonstrated a decrease in nodule size to 2.3 cm with evidence of intralesional hemorrhage, and catecholamine levels subsequently normalized, leading to deferral of adrenalectomy. At 6-month follow-up, transthoracic echocardiography showed normalization of left ventricular function, and repeat abdominal computed tomography revealed marked reduction in the adrenal mass. At 1 year, she remains asymptomatic with normal biochemical testing.