2. Case report:
A 40-year-old woman was admitted to the emergency department for an acute shortness of breath.
Three days before her admission she presented epigastralgia, vomiting and myalgia.
On physical examination: temperature= 38°C, BP= 100/60 mmHg, HR= 100 bpm, SpO2 100% with oxygen therapy at 15 l/min.
These findings led to the suspicion of a Sars-Cov2 infection.
Blood examinations showed the following results: white blood cells: 27,000 /μL (normal 4000-10000); lymphopenia: 700/µl (1000-4000); C-reactive protein 35 mg/L (normal <5); troponin: 8.84 ng/mL (normal <0.05); BNP 270 pg/ml (normal <74); CK : 532 UI/l (normal<171).
The chest CT revealed asymmetric and diffuse ground glass opacities associated with septal thickening, consolidations and confluent nodules (Fig.1) compatible with Covid-19 pneumonia.
Three COVID-19 PCR tests were negative.
The day following his admission, the patient presented an acute chest pain with tachycardia, hypotension, confusion and cardiac arrest. The patient was successfully resuscitated, intubated, and mechanically ventilated.
The ECG showed a sinus tachycardia at 110 bpm with ST segment depression in the inferolateral leads.
Transthoracic echocardiography (TTE) revealed left ventricular septico apical hypokinesis with ejection fraction (LVEF) of 20%.
Blood examinations gave the following values: troponin : 9 ng/mL; BNP 1558 pg/ml ; white blood cells, 27.000/μL.
Anti-nuclear antibodies and serological tests for the most common cardiotropic viruses were negative. Multiple blood, urine and bronchial aspirate cultures were sterile. Coronary angiography was normal.
Thus, the diagnosis of myocarditis complicated with pulmonary edema and cardiac arrest was made based on: hypoxemia, localized depolarization disorder, echocardiographic findings and abnormal cardiac biomarkers.
Cardiac magnetic resonance imaging (MRI) wasn’t done because of tachycardia and dyspnea.
A second chest scan (9 days later the first) showed the disappearance of the opacities (Fig.2).
The Sars-Cov2 pneumonia was eliminated because of a negative PCR, serologies and the quick disappearance of the ground-glass opacities.
CT slices exploring the upper abdominal floor showed a heterogeneous mass on the left adrenal gland, measuring 52×46 mm with hyperdense component suggesting hemorrhagic content (Fig.3). MRI examination showed a heterogenous adrenal mass with hypersignal areas on T1 weighted images related to hemorrhage (Fig.4).
After stabilization, the patient was referred to the Endocrinology Department for further exploration.
Laboratory tests of 72-hour urine catecholamines metabolites revealed mildly increased normetanephrine, but normal metanephrine as shown in table 1. The diagnosis of pheohromocytoma was suspected.