DIAGNOSTIC DILEMMA Aimee K. Zaas, MD, Section Editor Think, Diagnose, and Rethink Jennifer E. Sohn, MD, a Julia P. Dunn, MD, a Holly Burford, MD, b Martin Heslin, MD, c J. Michael Moates, MD a,d Departments of a Medicine, b Pathology, and c Surgery, and the d Division of Endocrinology and Metabolism, University of Alabama at Birmingham School of Medicine, Birmingham. PRESENTATION A 45-year-old healthy white male had signs and symp- toms indicative of a myocardial infarction, but his re- sponse to the typical treatment protocol spurred doubts. He presented to his local emergency department com- plaining of pain in the left side of the chest and the left upper quadrant that had begun 90 minutes earlier. On that morning, he had developed a severe headache, followed by nausea, vomiting, diaphoresis, and pallor. Twenty minutes later, he noted sharp pain in the lower left side of the chest and the left upper quadrant, and this was asso- ciated with lightheadedness, palpitations, and dyspnea. His family and social histories had no elements of con- cern, and he was without risk factors for coronary artery disease. He received regular care from a physician but took no medications. ASSESSMENT The patient had a blood pressure of 179/102 mm Hg and a heart rate of 71 beats per minute. He was in moderate distress and pain. Cardiovascular, lung, and abdominal ex- aminations were unremarkable. Laboratory studies initially revealed negative cardiac markers, a potassium level of 2.6 meq/L, and a hematocrit of 47%. An electrocardiogram (ECG) showed ST-segment depressions in the anterior leads and a right bundle branch block (Figure 1). Therapy for presumed non-ST-elevation myocardial in- farction was initiated with aspirin, morphine, metoprolol, heparin, eptifibatide, and nitroglycerin. The patient’s chest pain improved, but his left upper-quadrant pain progres- sively worsened. Abdominal computed tomography showed a large left-adrenal mass with surrounding fluid suggestive of hemorrhage (Figure 2). A repeat hematocrit identified a decrease from 47% to 37%. Anticoagulation was discontin- ued, and the patient was transferred to a tertiary care center, where repeat cardiac markers confirmed myocardial injury (Table 1). DIAGNOSIS A more detailed history revealed that the patient had experienced paroxysmal headaches, palpitations, tremulous- ness, and pallor of the hands for the past year. Biochemical evaluation for the adrenal mass disclosed elevations in urinary metanephrines and fractionated catecholamines; both are consistent with pheochromocytoma (Table 2). The patient’s ECG returned to normal by the second hospital day, and he remained free of chest pain through- out the admission. Of the few cases of hemorrhagic pheochromocytoma reported in the literature, approximately one-third resulted in death. 1-3 Hemorrhage into these highly vascular tumors is generally spontaneous, and the etiology is uncertain. Pre- sentation with hypertensive crisis seems to be dispropor- tionately associated with acute hemorrhage. 4 Only 3 cases of hemorrhagic pheochromocytoma attributable to antico- agulation have been reported. 5-7 At the time of our patient’s presentation, it was virtu- ally impossible to determine that a pheochromocytoma was responsible for the observed signs and symptoms. The initial impression of myocardial injury was appro- priate, given the clinical presentation and ECG findings, and this was later confirmed by positive cardiac enzymes. However, the diagnosis of non-ST-elevation myocardial infarction was not entirely accurate. Although this patient Funding: None. Conflict of Interest: None. Authorship: This manuscript has been reviewed by all authors. The work is original and all authors meet the criteria for authorship, includ- ing acceptance of responsibility for the scientific content of the manu- script. Requests for reprints should be addressed to Jennifer E. Sohn, MD, University of Alabama at Birmingham, FOT 702, 1530 3rd Ave South, Birmingham, AL 35294-3407. E-mail address: jsohn@uab.edu 0002-9343/$ -see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.amjmed.2009.05.006