Pheochromocytoma differential diagnosis: Difference between revisions
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* [[Anxiety]] often resembling that of a [[panic attack]] | * [[Anxiety]] often resembling that of a [[panic attack]] | ||
* [[Sweating]] | * [[Sweating]] | ||
* [[Headaches]] | * [[Headaches]] occur in 90 % of patients. | ||
* paroxysmal attacks of [[hypertension]] but some patients have normal blood pressure. | * paroxysmal attacks of [[hypertension]] but some patients have normal blood pressure. | ||
* May be asymptomatic and discovered by incidence screening especially [[MEN, type 2|MEN]] patients. | * May be asymptomatic and discovered by incidence screening especially [[MEN, type 2|MEN]] patients. | ||
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* [[Orthostatic hypotension]] | * [[Orthostatic hypotension]] | ||
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'''High risk patients''': plasma fractionated metanephrines is the first test | '''High-risk patients''': plasma fractionated metanephrines is the first test if elevated; 24-hour urinary fractionated metanephrines, catecholamines, and imaging should be the second test for diagnosis. <sup>[[Pheochromocytoma laboratory findings#cite note-pmid11903030-2|[2]]]</sup> | ||
'''Low risk patients''': 24-hour urinary fractionated catecholamines and metanephrines.<sup>[[Pheochromocytoma laboratory findings#cite note-pmid12574179-4|[4]]]</sup> | '''Low-risk patients''': 24-hour urinary fractionated catecholamines and metanephrines.<sup>[[Pheochromocytoma laboratory findings#cite note-pmid12574179-4|[4]]]</sup> | ||
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|Pseudopheochromocytoma | |Pseudopheochromocytoma | ||
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|Panic attacks | |Panic attacks | ||
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* | * Paroxysms of increased sympathetic activity. | ||
* Characterized by episodes of fear or panic | * Characterized by episodes of fear or panic | ||
* Such as | * Such as pseudo pheochromocytoma, panic disorders are usually | ||
associated with physical symptoms such as chest pain, headache, palpitations, flushing and both respond to antidepressants. | associated with physical symptoms such as chest pain, headache, palpitations, flushing and both respond to antidepressants. | ||
''<u>In panic attacks fear precedes | ''<u>In panic attacks, fear precedes physical symptoms. By contrast, in pseudo pheochromocytoma physical symptoms occur before feeling fear.</u>'' | ||
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|Hyperthyroidism | |Hyperthyroidism | ||
|Symptoms of hyperthyroidism include | |Symptoms of hyperthyroidism include weight loss, heat intolerance, tremor, palpitations, anxiety, increased bowel disturbances, and shortness of breath. <ref name="pmid15963064">{{cite journal| author=Iglesias P, Acosta M, Sánchez R, Fernández-Reyes MJ, Mon C, Díez JJ| title=Ambulatory blood pressure monitoring in patients with hyperthyroidism before and after control of thyroid function. | journal=Clin Endocrinol (Oxf) | year= 2005 | volume= 63 | issue= 1 | pages= 66-72 | pmid=15963064 | doi=10.1111/j.1365-2265.2005.02301.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15963064 }}</ref> | ||
|Goiter, skin flushing and eye proptosis. | |Goiter, skin flushing and eye proptosis. | ||
Increased sensitivity of beta receptors in heart to catecholamines <ref name="pmid20454652">{{cite journal| author=Mintz G, Pizzarello R, Klein I| title=Enhanced left ventricular diastolic function in hyperthyroidism: noninvasive assessment and response to treatment. | journal=J Clin Endocrinol Metab | year= 1991 | volume= 73 | issue= 1 | pages= 146-50 | pmid=2045465 | doi=10.1210/jcem-73-1-146 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2045465 }}</ref> due to effect of thyroid hormones increase cardiac work and output and systolic hypertension.<ref name="pmid2045465">{{cite journal| author=Mintz G, Pizzarello R, Klein I| title=Enhanced left ventricular diastolic function in hyperthyroidism: noninvasive assessment and response to treatment. | journal=J Clin Endocrinol Metab | year= 1991 | volume= 73 | issue= 1 | pages= 146-50 | pmid=2045465 | doi=10.1210/jcem-73-1-146 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2045465 }}</ref> | Increased sensitivity of beta receptors in the heart to catecholamines <ref name="pmid20454652">{{cite journal| author=Mintz G, Pizzarello R, Klein I| title=Enhanced left ventricular diastolic function in hyperthyroidism: noninvasive assessment and response to treatment. | journal=J Clin Endocrinol Metab | year= 1991 | volume= 73 | issue= 1 | pages= 146-50 | pmid=2045465 | doi=10.1210/jcem-73-1-146 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2045465 }}</ref> due to an effect of thyroid hormones increase cardiac work and output and systolic hypertension.<ref name="pmid2045465">{{cite journal| author=Mintz G, Pizzarello R, Klein I| title=Enhanced left ventricular diastolic function in hyperthyroidism: noninvasive assessment and response to treatment. | journal=J Clin Endocrinol Metab | year= 1991 | volume= 73 | issue= 1 | pages= 146-50 | pmid=2045465 | doi=10.1210/jcem-73-1-146 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2045465 }}</ref> | ||
|Low thyroid-stimulating hormone (TSH) high free thyroxine (T4) and triiodothyronine (T3) concentrations. | |Low thyroid-stimulating hormone (TSH) high free thyroxine (T4) and triiodothyronine (T3) concentrations. | ||
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* Vision changes, including seeing flashing lights | * Vision changes, including seeing flashing lights | ||
* Rarely, hallucinations (seeing things that aren't there) | * Rarely, hallucinations (seeing things that aren't there) | ||
* Falling, loss of muscle control | * Falling, loss of muscle control occurs very suddenly | ||
* Muscle twitching that may spread up or down an arm or leg | * Muscle twitching that may spread up or down an arm or leg | ||
* Muscle tension or tightening that causes twisting of the body, head, arms, or legs | * Muscle tension or tightening that causes twisting of the body, head, arms, or legs | ||
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* Tasting a bitter or metallic flavor | * Tasting a bitter or metallic flavor | ||
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|An isolated abnormal electrical activity recorded by an [[electroencephalography]] examination without a clinical presentation is called | |An isolated abnormal electrical activity recorded by an [[electroencephalography]] examination without a clinical presentation is called sub clinical seizure. They may identify background epileptogenic activity, as well as help identify particular causes of seizures. | ||
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|[[Carcinoid syndrome]] | |[[Carcinoid syndrome]] | ||
|Hypertensive crisis occurs with malignant carcinoid syndrome <ref name="pmid7969229">{{cite journal| author=Warner RR, Mani S, Profeta J, Grunstein E| title=Octreotide treatment of carcinoid hypertensive crisis. | journal=Mt Sinai J Med | year= 1994 | volume= 61 | issue= 4 | pages= 349-55 | pmid=7969229 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7969229 }}</ref> should be distinguished from pheochromocytoma. Patient | |Hypertensive crisis occurs with malignant carcinoid syndrome <ref name="pmid7969229">{{cite journal| author=Warner RR, Mani S, Profeta J, Grunstein E| title=Octreotide treatment of carcinoid hypertensive crisis. | journal=Mt Sinai J Med | year= 1994 | volume= 61 | issue= 4 | pages= 349-55 | pmid=7969229 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7969229 }}</ref> should be distinguished from pheochromocytoma. Patient | ||
|Cutaneous flushing Venous telangiectasia Diarrhea Bronchospasm Cardiac valvular lesions : tricusped | |Cutaneous flushing Venous telangiectasia Diarrhea Bronchospasm Cardiac valvular lesions: tricusped incompeence. | ||
| | | | ||
* High urinary excretion of 5-HIAA <ref name="pmid3227292">{{cite journal| author=Sjöblom SM| title=Clinical presentation and prognosis of gastrointestinal carcinoid tumours. | journal=Scand J Gastroenterol | year= 1988 | volume= 23 | issue= 7 | pages= 779-87 | pmid=3227292 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3227292 }}</ref> | * High urinary excretion of 5-HIAA <ref name="pmid3227292">{{cite journal| author=Sjöblom SM| title=Clinical presentation and prognosis of gastrointestinal carcinoid tumours. | journal=Scand J Gastroenterol | year= 1988 | volume= 23 | issue= 7 | pages= 779-87 | pmid=3227292 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3227292 }}</ref> | ||
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|[[Migraine headaches]] | |[[Migraine headaches]] | ||
|[[prodrome|(1) '''Prodrome,''']] which occurs hours or days before | |[[prodrome|(1) '''Prodrome,''']] which occurs hours or days before a headache. | ||
(2) '''[[Aura (symptom)|Aura]],''' which immediately precedes the headache | (2) '''[[Aura (symptom)|Aura]],''' which immediately precedes the headache. | ||
(3) [[Pain and nociception|'''the pain phase,''']] also known as headache phase and | (3) [[Pain and nociception|'''the pain phase,''']] also known as headache phase and | ||
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* Migraine attacks that begin after 50 years of age | * Migraine attacks that begin after 50 years of age | ||
'''[[CT]] is not indicated in:''' | '''[[CT]] is not indicated in:''' | ||
* Patients with a diagnosis of migraine in accordance with the [[Migraine classification|criteria for migraine]]. | * Patients with a diagnosis of a migraine in accordance with the [[Migraine classification|criteria for migraine]]. | ||
* Differentiating a migraine from other primary [[headaches]] | * Differentiating a migraine from other primary [[headaches]] | ||
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* Disturbed consciousness. | * Disturbed consciousness. | ||
* nasal septum perforation in cocaine addiction. | * nasal septum perforation in cocaine addiction. | ||
* Needle marks in skin. | * Needle marks in the skin. | ||
* History of antidepressants intake. | * History of antidepressants intake. | ||
|Toxicology screening | |Toxicology screening | ||
Revision as of 13:59, 21 July 2017
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Pheochromocytoma Microchapters |
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Pheochromocytoma differential diagnosis On the Web |
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Risk calculators and risk factors for Pheochromocytoma differential diagnosis |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ahmad Al Maradni, M.D. [2] Mohammed Abdelwahed M.D[3]
Overview
Pheochromocytoma must be differentiated from other causes of paroxysmal hypertension including: severe paroxysmal hypertension (Pseudopheochromocytoma)
, panic disorder, Factitious hypertension, carcinoid syndrome, Migraine headache, Hyperthyroidism, Renovascular hypertension, Hypoglycemia, Labile hypertension (White coat hypertension), Stroke and compression of lateral medulla, Seizures, Baroreflex failure and drugs.
Differentiating pheochromocytoma from other diseases
Pheochromocytoma must be differentiated from other causes of paroxysmal hypertension including: severe paroxysmal hypertension (Pseudopheochromocytoma)
, panic disorder, Factitious hypertension, carcinoid syndrome, Migraine headache, Hyperthyroidism, Renovascular hypertension, Hypoglycemia and drugs.
| Disease | Symptoms | Signs | Investigations |
|---|---|---|---|
| Pheochromocytoma | The hallmark symptoms of a pheochromocytoma are those of sympathetic nervous system hyperactivity, symptoms usually subside in less than one hour and they may include:
Please note that not all patients with pheochromocytoma experience all classical symptoms.[4] |
Common physical exam findings include:
|
High-risk patients: plasma fractionated metanephrines is the first test if elevated; 24-hour urinary fractionated metanephrines, catecholamines, and imaging should be the second test for diagnosis. [2] Low-risk patients: 24-hour urinary fractionated catecholamines and metanephrines.[4] |
| Pseudopheochromocytoma | Paroxysmal activation of the sympathetic system causing hypertension and tachycardia [1]that responds to alpha/beta blockade.[2]Disorder is usually related to emotional distress.
Acute onset of high blood pressure, headache, chest pain, nausea, palpitations, flushing. Duration of attacks ranges from minutes to hours. |
Increase in plasma catecholamines between and during attacks.[3][4] | |
| Panic attacks |
associated with physical symptoms such as chest pain, headache, palpitations, flushing and both respond to antidepressants. In panic attacks, fear precedes physical symptoms. By contrast, in pseudo pheochromocytoma physical symptoms occur before feeling fear. |
Laboratory studies that can exclude medical disorders other than panic disorder include:
| |
| Labile hypertension (White coat hypertension) | Patients exhibit elevated blood pressure in a clinical setting but not in other settings.[1] | Ambulatory blood pressure monitoring and patient self-measurement using a home blood pressure monitoring device are being increasingly used to differentiate patients with white coat hypertension from patients with true hypertension. | Normal |
| Hyperthyroidism | Symptoms of hyperthyroidism include weight loss, heat intolerance, tremor, palpitations, anxiety, increased bowel disturbances, and shortness of breath. [5] | Goiter, skin flushing and eye proptosis.
Increased sensitivity of beta receptors in the heart to catecholamines [6] due to an effect of thyroid hormones increase cardiac work and output and systolic hypertension.[7] |
Low thyroid-stimulating hormone (TSH) high free thyroxine (T4) and triiodothyronine (T3) concentrations. |
| Renovascular hypertension |
|
(bruit) can be heard over the abdomen. | Diagnosis by Duplex ultrasonography is considered class I recommendation. It may be used as an initial screening tool for diagnosis of atherosclerotic renal artery stenosis. Ultrasonography might not be very accurate in obese patients or those intestinal gas.[1] |
| Stroke and compression of lateral medulla | Extensive unilateral infarction of the brain stem in the region of the nucleus tractus solitarius may result in partial baroreflex dysfunction, increased sympathetic activity, and neurogenic paroxysmal hypertension.[8] | CT shows mass compressing lateral medulla or infarction in the same area. | |
| Seizures | According to type:
|
An isolated abnormal electrical activity recorded by an electroencephalography examination without a clinical presentation is called sub clinical seizure. They may identify background epileptogenic activity, as well as help identify particular causes of seizures. | |
| Carcinoid syndrome | Hypertensive crisis occurs with malignant carcinoid syndrome [9] should be distinguished from pheochromocytoma. Patient | Cutaneous flushing Venous telangiectasia Diarrhea Bronchospasm Cardiac valvular lesions: tricusped incompeence. |
|
| Migraine headaches | (1) Prodrome, which occurs hours or days before a headache.
(2) Aura, which immediately precedes the headache. (3) the pain phase, also known as headache phase and |
|
CT is indicated in patients with: [1] [2]
CT is not indicated in:
|
| Drugs | Sympathomimetic drugs that can induce symptoms simulating pheochromocytoma include high-dose phenylpropanolamin, cocaine, amphetamine, LSD, PCP. [15] Combination of a monoamine oxidase (MAO) inhibitor and ingestion of tyramine-containing foods.[16] |
|
Toxicology screening |
| Baroreflex failure |
|
Neck CT |
- ↑ Mann SJ (1999). "Severe paroxysmal hypertension (pseudopheochromocytoma): understanding the cause and treatment". Arch Intern Med. 159 (7): 670–4. PMID 10218745.
- ↑ Mann SJ (1999). "Severe paroxysmal hypertension (pseudopheochromocytoma): understanding the cause and treatment". Arch Intern Med. 159 (7): 670–4. PMID 10218745.
- ↑ Mann SJ (1996). "Severe paroxysmal hypertension. An automatic syndrome and its relationship to repressed emotions". Psychosomatics. 37 (5): 444–50. doi:10.1016/S0033-3182(96)71532-3. PMID 8824124.
- ↑ Sharabi Y, Goldstein DS, Bentho O, Saleem A, Pechnik S, Geraci MF; et al. (2007). "Sympathoadrenal function in patients with paroxysmal hypertension: pseudopheochromocytoma". J Hypertens. 25 (11): 2286–95. doi:10.1097/HJH.0b013e3282ef5fac. PMID 17921824.
- ↑ Iglesias P, Acosta M, Sánchez R, Fernández-Reyes MJ, Mon C, Díez JJ (2005). "Ambulatory blood pressure monitoring in patients with hyperthyroidism before and after control of thyroid function". Clin Endocrinol (Oxf). 63 (1): 66–72. doi:10.1111/j.1365-2265.2005.02301.x. PMID 15963064.
- ↑ Mintz G, Pizzarello R, Klein I (1991). "Enhanced left ventricular diastolic function in hyperthyroidism: noninvasive assessment and response to treatment". J Clin Endocrinol Metab. 73 (1): 146–50. doi:10.1210/jcem-73-1-146. PMID 2045465.
- ↑ Mintz G, Pizzarello R, Klein I (1991). "Enhanced left ventricular diastolic function in hyperthyroidism: noninvasive assessment and response to treatment". J Clin Endocrinol Metab. 73 (1): 146–50. doi:10.1210/jcem-73-1-146. PMID 2045465.
- ↑ Phillips AM, Jardine DL, Parkin PJ, Hughes T, Ikram H (2000). "Brain stem stroke causing baroreflex failure and paroxysmal hypertension". Stroke. 31 (8): 1997–2001. PMID 10926969.
- ↑ Warner RR, Mani S, Profeta J, Grunstein E (1994). "Octreotide treatment of carcinoid hypertensive crisis". Mt Sinai J Med. 61 (4): 349–55. PMID 7969229.
- ↑ Sjöblom SM (1988). "Clinical presentation and prognosis of gastrointestinal carcinoid tumours". Scand J Gastroenterol. 23 (7): 779–87. PMID 3227292.
- ↑ Feldman JM (1986). "Urinary serotonin in the diagnosis of carcinoid tumors". Clin Chem. 32 (5): 840–4. PMID 2421946.
- ↑ Eriksson B, Arnberg H, Oberg K, Hellman U, Lundqvist G, Wernstedt C; et al. (1990). "A polyclonal antiserum against chromogranin A and B--a new sensitive marker for neuroendocrine tumours". Acta Endocrinol (Copenh). 122 (2): 145–55. PMID 2316306.
- ↑ Sundin A, Vullierme MP, Kaltsas G, Plöckinger U, Mallorca Consensus Conference participants. European Neuroendocrine Tumor Society (2009). "ENETS Consensus Guidelines for the Standards of Care in Neuroendocrine Tumors: radiological examinations". Neuroendocrinology. 90 (2): 167–83. doi:10.1159/000184855. PMID 19077417.
- ↑ Kelman L (2004). "The premonitory symptoms (prodrome): a tertiary care study of 893 migraineurs". Headache. 44 (9): 865–72. doi:10.1111/j.1526-4610.2004.04168.x. PMID 15447695.
- ↑ Krentz AJ, Mikhail S, Cantrell P, Hill GM (2001). "Drug Points: Pseudophaeochromocytoma syndrome associated with clozapine". BMJ. 322 (7296): 1213. PMC 31620. PMID 11358774.
- ↑ Kuchel O (1985). "Pseudopheochromocytoma". Hypertension. 7 (1): 151–8. PMID 3980057.
- ↑ Zar T, Peixoto AJ (2008). "Paroxysmal hypertension due to baroreflex failure". Kidney Int. 74 (1): 126–31. doi:10.1038/ki.2008.30. PMID 18322544.
- ↑ Zar T, Peixoto AJ (2008). "Paroxysmal hypertension due to baroreflex failure". Kidney Int. 74 (1): 126–31. doi:10.1038/ki.2008.30. PMID 18322544.