Recurrent Takotsubo Syndrome and Pulmonary Embolism Revealing a Pheochromocytoma: A Diagnostic Pitfall

Stress cardiomyopathy (Takotsubo syndrome or TTS) is an acute and reversible left ventricular dysfunction typically triggered by emotional or physical stress. Although most cases are idiopathic, secondary causes should be suspected in cases of recurrence, unusual severity, or atypical presentation. The association between TTS and pulmonary embolism (PE) is rare and may lead to diagnostic pitfalls, particularly when left ventricular dysfunction is misinterpreted as a marker of embolic severity. We report the case of a 46-year-old woman with two episodes of TTS one year apart. The second episode, presenting as a reverse Takotsubo pattern, was complicated by cardiogenic shock and multiorgan failure. A thoraco-abdominopelvic CT scan performed during etiological workup revealed a subsegmental PE without right ventricular dysfunction. The diagnosis of TTS was confirmed by ventriculography, demonstrating characteristic wall motion abnormalities in the absence of obstructive coronary artery disease. The diagnosis of pheochromocytoma was established based on concordant imaging findings (abdominal CT and positron emission tomography revealing an adrenal mass) and biochemical confirmation with markedly elevated plasma and urinary metanephrine levels. This case highlights the importance of investigating secondary causes in recurrent or atypical TTS and emphasizes that, in the setting of PE associated with left ventricular dysfunction, concomitant cardiomyopathy should be considered rather than attributing findings solely to embolic severity.