P33: Electroconvulsive therapy for treatment-resistant depression in a patient with hereditary paraganglioma/pheochromocytomasyndrome

Abstract

Introduction: Cardiac complications during electroconvulsive therapy (ECT) occur more frequently in medically frail, geriatric patients and those with catecholamine-secreting tumors including pheochromocytoma (PCC) or paraganglioma (PGL). Patients with hereditary PGL/PCC syndromes develop these tumors at higher rates, however, little is known of the safety of ECT in individuals with hereditary PGL/PCC without an active tumor who may benefit from treatment.

Methods: A case report of a patient with hereditary PGL/PCC receiving ECT for treatment resistant depression (TRD) and a literature review are presented.

Results: 59-year-old female with hereditary PGL/PCC (TMEM 127 mutation, family history), hypothyroidism, essential tremor, migraine, and TRD, presenting for hospitalization to initiate ECT for her TRD >20 years that consisted of persistent hopelessness, anhedonia, and depressed mood with two hospitalizations for suicidal ideation. Upon admission, her medications were adjusted to bupropionXR 300mg and nortriptyline 25mg at bedtime. She complained of headaches and sweating but has no history of hypertension. No abnormalities were found on 24-hour urine metanephrine, ECG, or PET-CT. Her geriatric psychiatry team, in collaboration with anesthesiology and endocrinology, felt it safe to proceed with ECT. To date, the acute course has consisted of 6 ultrabrief right unilateral ECT treatments, all without hemodynamic complications (systolic blood pressure ∼120- 150, heart rate ∼60-90). Mood, interest, motivation, and energy are improving, and passive suicidal ideation has resolved. Beck’s Depression Inventory (BDI) score decreased from 33 to 29, Clinical Global Impression (CGI) Severity score decreased from 6 to 4, and CGI Improvement score was 3.

Conclusions: PCC was previously considered an absolute contraindication to ECT based on the limited literature on the subject. While a recent systematic review recommended conducting a risk-benefit analysis before ECT in patients with PCC, there are no known cases describing approaches to ECT in patients with hereditary PGL/PCC in the absence of an active tumor. This case exemplifies the safety and efficacy of ECT in an older patient with hereditary PGL/PCC, who received careful evaluation and monitoring. The benefits of ECT for TRD in older individuals with hereditary PGL/PCC may outweigh potential risks of treatment, and complications can be mitigated through multidisciplinary pre-treatment medical evaluations and comprehensive periprocedural monitoring.