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(b) Osmoscan curve showing a flat curve in SAO patient confirming decreased RBC deformability (<span class="elsevierStyleItalic">green</span>: normal patient; <span class="elsevierStyleItalic">orange</span>: patient with South-East Asian ovalocytosis).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Marta Canelo-Vilaseca, Inés Hernández-Rodríguez, José-Tomás Navarro" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Marta" "apellidos" => "Canelo-Vilaseca" ] 1 => array:2 [ "nombre" => "Inés" "apellidos" => "Hernández-Rodríguez" ] 2 => array:2 [ "nombre" => "José-Tomás" "apellidos" => "Navarro" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020623005351?idApp=UINPBA00004N" "url" => "/23870206/0000016200000001/v2_202401260813/S2387020623005351/v2_202401260813/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Atypical tako-tsubo syndrome as a presentation of adrenal pheochromocytoma" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "44" "paginaFinal" => "45" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Cristóbal Fraga Abelleira, María Cespón Fernández" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Cristóbal" "apellidos" => "Fraga Abelleira" "email" => array:1 [ 0 => "csfraga1994@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "María" "apellidos" => "Cespón Fernández" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Endocrinología, Complexo Hospitalario Universitario de Vigo, Vigo, Pontevedra, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Cardiología, Complexo Hospitalario Universitario de Vigo, Vigo, Pontevedra, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Síndrome de tako-tsubo atípico como presentación de feocromocitoma adrenal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 698 "Ancho" => 1007 "Tamanyo" => 81912 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Septate cystic lesion in the right adrenal gland, consistent with adrenal pheochromocytoma.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Stress cardiomyopathy or tako-tsubo syndrome (TTS) is a type of non-ischaemic cardiomyopathy in which there is a transient loss of contractile capacity of the myocardium, usually as a consequence of a stressor, often of an emotional nature. The usual ultrasound pattern shows apical dilatation with hyperkinesia of the basal segments.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> There is an “atypical” or “inverted” presentation, estimated to account for about 20% of all cases, which has different ultrasound features from the above, with hypokinesia of the basal segments and hypercontractility in the apical region.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> It is not clearly established whether there is a significant difference in mortality between the two variants, although current evidence suggests that atypical forms probably have a slightly lower mortality rate.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Recent reviews report a small number of cases of inverted TTS syndrome associated with pheochromocytoma.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> We report 2 cases of pheochromocytoma that started clinically as inverted TTS.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The first case is a 68-year-old male patient, with no history of interest, who presented with syncope and subsequent dyspnoea, accompanied by central chest pain radiating to the left upper limb. The electrocardiogram showed ST-segment depression in inferolateral leads, which subsequently progressed to ventricular tachycardia. The patient required non-invasive mechanical ventilation and amine support for blood pressure control. Echocardiography showed hypokinesia in basal segments with apical hypercontractility, a pattern compatible with inverted or atypical TTS. Peak troponin Ic was 20,840 pg/ml (5–125) and LVEF at that time was 51%, with no lesions observed on coronary angiography. The cardiac MRI incidentally showed a left adrenal mass, so an abdominal CT scan was requested, which confirmed the presence of a mass in the left adrenal gland, measuring 3.6 cm, with elevated plasma metanephrine levels: 3119 ng/l (8–88) and normetanephrine: 1439 ng/l (20–135).</p><p id="par0020" class="elsevierStylePara elsevierViewall">The patient completed alpha and beta blockade and underwent surgical excision of the lesion, confirming remission of adrenergic activity and normal LVEF at discharge.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The second case is a 55-year-old woman, smoker since her youth and with no other history of interest, who presented to the emergency department with headache and anxiety attacks which started early morning on the same day, without chest pain. Blood pressure recorded in the ED was 190/120 mmHg and the electrocardiogram showed ST-segment elevation in V2-V6, as well as in V2, <span class="elsevierStyleSmallCaps">V2</span>, <span class="elsevierStyleSmallCaps">V3</span> and VF, with frequent ventricular extrasystoles. Peak troponin Ic was 510 ng/l (0–53). Echocardiography showed an LVEF of 25%, with apical hypercontractility, mid-segment hypokinesia and basal akinesia. Coronary angiography showed no significant lesions, so the diagnosis of TTS was confirmed. The patient started shortly afterwards with dyspnoea and heart failure symptoms requiring non-invasive mechanical ventilation and support in the intensive care unit.</p><p id="par0030" class="elsevierStylePara elsevierViewall">With the experience gained from the previous case in our centre, an adrenergic function study was performed, followed by an abdominal CT scan, which revealed a cystic right adrenal mass measuring 6.8 × 7.2 cm, compatible with pheochromocytoma (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), and elevated plasma levels of metanephrine (404 ng/l; 8–88) and normetanephrine (353 ng/l; 20–135). The patient completed alpha- and beta-blockade in preparation for surgery to remove the mass, and pathological anatomy confirmed the diagnosis. At discharge, both LVEF and metanephrine levels were completely normal.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">In conclusion, both the usual form of TTS and its "inverted or atypical" variant is a disease that may mask the presence of a catecholamine-producing tumour. Given its potential severity and the existence of a curative treatment in most cases, screening should be considered in these patients. As the first case illustrates, and since cardiac MRI is one of the tests of choice in the diagnosis of TTS, it would be advisable to expand the field to include upper abdominal views in order to include the adrenal glands as part of this screening.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethical considerations</span><p id="par0040" class="elsevierStylePara elsevierViewall">Informed consents have been obtained from the patients whose clinical cases appear in this paper.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0045" class="elsevierStylePara elsevierViewall">No external funding has been received for the drafting of this text.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest in the subject matter of this manuscript.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Ethical considerations" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Funding" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 698 "Ancho" => 1007 "Tamanyo" => 81912 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Septate cystic lesion in the right adrenal gland, consistent with adrenal pheochromocytoma.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Takotsubo syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A. 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Elsaesser" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/hrt.2006.101675" "Revista" => array:6 [ "tituloSerie" => "Heart" "fecha" => "2007" "volumen" => "93" "paginaInicial" => "1309" "paginaFinal" => "1315" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17890711" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Differences in the clinical profile and outcomes of typical and atypical Takotsubo syndrome. Data From the International Takotsubo Registry" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J. Ghadri" 1 => "V. Cammann" 2 => "C. 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Lee" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ijcard.2022.08.053" "Revista" => array:6 [ "tituloSerie" => "Int J Cardiol" "fecha" => "2023" "volumen" => "371" "paginaInicial" => "287" "paginaFinal" => "292" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/36055473" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000016200000001/v2_202401260813/S238702062300517X/v2_202401260813/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000016200000001/v2_202401260813/S238702062300517X/v2_202401260813/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S238702062300517X?idApp=UINPBA00004N" ]
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Vol. 162. Issue 1.
Pages 44-45 (January 2024)
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Vol. 162. Issue 1.
Pages 44-45 (January 2024)
Letter to the Editor
Atypical tako-tsubo syndrome as a presentation of adrenal pheochromocytoma
Síndrome de tako-tsubo atípico como presentación de feocromocitoma adrenal
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