Endomyocardial Biopsy in acute cardiogenic shock: Diagnosis of pheochromocytoma

Acute cardiogenic shock is a clinical emergency. Once the most common causes including acute myocardial ischemia and acute valve dysfunction are excluded, less common causes such as toxic cardiomyopathy or fulminant myocarditis remain to be investigated. Endomyocardial biopsy (EMB) is the gold standard to diagnose or rule out myocarditis and to suspect toxic acute myocardial damage in patients presenting with cardiogenic shock.
Our patient in cardiogenic shock was suspected of having fulminant myocarditis. EMB excluded this diagnosis: the contraction band necrosis was consistent with acute myocardial damage and the prominent fibrosis, while small vessel hyperplasia suggested pre-existing chronic myocardial damage. The contraction bands do not, by themselves, support catecholamine-induced myocardial damage because they are commonly seen in ischemic coagulative necrosis and as artefacts of endomyocardial biopsy procedure. The pathologic findings, the absence of myocarditis, the history of severe recurrent headaches and palpitations, the negative family history and the biomarkers demonstrating myocyte necrosis supported the diagnostic hypothesis of toxic acute myocardial damage. The written report of the EMB, indicating the possibility of a pheochromocytoma or paraganglioma, called for immediate abdominal imaging that demonstrated the adrenal mass.