Pheochromocytoma with two rare manifestations: Non-ST segment myocardial infarction with normal coronary arteries and blue toe syndrome

Abstract

We present a 42-year-old man with acute coronary syndrome with normal coronary arteries and blue toe syndrome secondary to pheochromocytoma. The patient's medical history included paroxysmal atrial fibrillation and severe hypertension. He complained of weight loss, headache, excessive sweating, palpitations, and anxiety. He had a dry gangrene on the extremity of the left big toe. Pheochromocytoma was confirmed by extremely elevated normetanephrine and metanephrine serum levels (40 and 61 times the upper limit of normal, respectively). Pheochromocytoma was confirmed. An abdominal computed tomography scan showed a voluminous left adrenal mass. Angio-computed tomography-scan of the lower extremities revealed normal arteries. The patient was treated with an alpha-adrenergic blocker, a beta-adrenergic blocker, and a calcium channel blocker. After discontinuation of the treatment by the patient, he presented with constrictive chest pain, blood pressure crisis, and palpitations. The diagnosis of non-ST segment elevation myocardial infarction was made. Coronary angiography revealed normal arteries. Antihypertensive treatment was reintroduced and a left adrenalectomy was performed without incidents. Ten days after surgery, blood pressure, heart rate, and electrocardiogram were normal. There was a significant improvement in the dry gangrene on the left big toe, 4 days after surgery. Pheochromocytoma may present with unusual clinical manifestations such as acute coronary syndrome and peripheral limb ischemia. Timely diagnosis and management of pheochromocytoma are crucial, as the manifestations in this case disappeared after the pheochromocytoma was surgically removed.