Pheochromocytoma differential diagnosis

Revision as of 16:48, 31 July 2017 by Medhat (talk | contribs)
Jump to navigation Jump to search

Pheochromocytoma Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Pheochromocytoma from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

X Ray

CT

MRI

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

Pheochromocytoma differential diagnosis On the Web

Most recent articles

cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Pheochromocytoma differential diagnosis

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Pheochromocytoma differential diagnosis

CDC on Pheochromocytoma differential diagnosis

Pheochromocytoma differential diagnosis in the news

Blogs on Pheochromocytoma differential diagnosis

Directions to Hospitals Treating Pheochromocytoma

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 the 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 are 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
  • Paroxysms of increased sympathetic activity.
  • It is characterized by episodes of fear or panic
  • Such as pseudo-pheochromocytoma, panic disorders are usually 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 laboratory studies
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 stenosisUltrasonography might not be very accurate in obese patients or those intestinal gas.[1]
Stroke and compression of lateral medulla (Lateral medullary syndrome) 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; it may be focal or generalized, clinical or subclinical:
  • A person having a tonic-clonic seizure may have repetitive twitches of arm and legs. Patients may have tongue pittings and may lose consciousness.
  • Symptoms occur suddenly and may persist
  • Muscle tension or tightening that causes twisting of the body, head, arms, or legs.
  • Patients may have amnesia.
  • Mood changes for example; fear, panic, or laughter
  • Change in sensation of the skin over the arm, leg, or trunk
  • Vision changes and light flashes and may be hallucinations
  • Tasting a bitter or metallic flavor
  • A person having a complex partial seizure may appear confused or dazed and will not be able to respond to questions or direction.
  • absence seizure is a rapid blinking or a few seconds of staring into space.
An abnormal electroencephalography. Positive test without a clinical presentation is called sub clinical seizure. They may identify past or family history of epilepsy.
Carcinoid syndrome Hypertensive crisis occurs with malignant carcinoid syndrome [9] should be distinguished from pheochromocytoma. Cutaneous flushing Venous telangiectasia, diarrhea, bronchospasm and cardiac valvular lesions (tricuspid incompetence)
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

(4) The postdrome phase[14]

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 phenylpropanolamine, cocaine, amphetamine, LSD, PCP. [15] Combination of a monoamine oxidase (MAO) inhibitor and ingestion of tyramine-containing foods.[16] Toxicology screening
Baroreflex failure
  • Marked and frequent fluctuations in blood pressure, [17]with both high and low readings
  • It is caused by hypofunctioning of t-he baroreflexes that normally buffer blood pressure fluctuations.
  • The disorder is usually a result of injury to carotid baroreceptors, with most patients reporting a history of neck irradiation or surgery. [18]
Neck CT
  1. Mann SJ (1999). "Severe paroxysmal hypertension (pseudopheochromocytoma): understanding the cause and treatment". Arch Intern Med. 159 (7): 670–4. PMID 10218745.
  2. Mann SJ (1999). "Severe paroxysmal hypertension (pseudopheochromocytoma): understanding the cause and treatment". Arch Intern Med. 159 (7): 670–4. PMID 10218745.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. 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.
  9. 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.
  10. Sjöblom SM (1988). "Clinical presentation and prognosis of gastrointestinal carcinoid tumours". Scand J Gastroenterol. 23 (7): 779–87. PMID 3227292.
  11. Feldman JM (1986). "Urinary serotonin in the diagnosis of carcinoid tumors". Clin Chem. 32 (5): 840–4. PMID 2421946.
  12. 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.
  13. 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.
  14. 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.
  15. Krentz AJ, Mikhail S, Cantrell P, Hill GM (2001). "Drug Points: Pseudophaeochromocytoma syndrome associated with clozapine". BMJ. 322 (7296): 1213. PMC 31620. PMID 11358774.
  16. Kuchel O (1985). "Pseudopheochromocytoma". Hypertension. 7 (1): 151–8. PMID 3980057.
  17. 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.
  18. 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.