Pheochromocytoma differential diagnosis: Difference between revisions
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{{CMG}}; {{AE}} {{AAM}} | {{CMG}}; {{AE}} {{AAM}} | ||
==Overview== | |||
Pheochromocytoma must be differentiated from other causes of paroxysmal hypertension including: severe paroxysmal hypertension (Pseudopheochromocytoma) | |||
, [[Panic disorder|panic disorder,]] [[Factitious hypertension]], [[carcinoid syndrome]], [[Migraine|Migraine headache]], [[Hyperthyroidism|Hyperthyroidism,]] [[Insulinoma|Insulinoma,]] [[Renovascular hypertension|Renovascular hypertension,]] [[Hypoglycemia]] and drugs. | |||
DIFFERENTIAL DIAGNOSIS — In addition to pseudopheochromocytoma, the following diagnoses should be strongly considered among patients presenting with paroxysmal hypertension: | DIFFERENTIAL DIAGNOSIS — In addition to pseudopheochromocytoma, the following diagnoses should be strongly considered among patients presenting with paroxysmal hypertension: | ||
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●Labile hypertension | ●Labile hypertension | ||
●Panic disorder | ●Panic disorder Panic disorder can replicate many of the symptoms of pheochromocytoma because it is associated with increased sympathetic activity. Hypertension in these patients occurs primarily during treatment with a tricyclic antidepressant drug, which may increase the degree of sympathetic arousal. | ||
Pheochromocytoma — The diagnosis of pheochromocytoma must be excluded in all patients with unprovoked paroxysmal hypertension. Assays of plasma or urine catecholamines are diagnostic in 95 percent of patients with symptoms, and the high sensitivity of the plasma metanephrine assay is also documented | Pheochromocytoma — The diagnosis of pheochromocytoma must be excluded in all patients with unprovoked paroxysmal hypertension. Assays of plasma or urine catecholamines are diagnostic in 95 percent of patients with symptoms, and the high sensitivity of the plasma metanephrine assay is also documented | ||
pseudopheochromocytoma insist that the disorder is unrelated to psychologic factors. | |||
Panic disorder — Panic disorder is characterized by episodes of fear or panic, and is commonly associated with physical symptoms such as chest pain, headache, palpitations, flushing, and dizziness, along with some degree of blood pressure elevation [16-20]. Panic disorder and pseudopheochromocytoma share similar physical symptoms, and both respond to treatment with an antidepressant agent. As mentioned above, panic disorder is present in as many as 40 percent of patients evaluated for pseudopheochromocytoma, | Panic disorder — Panic disorder is characterized by episodes of fear or panic, and is commonly associated with physical symptoms such as chest pain, headache, palpitations, flushing, and dizziness, along with some degree of blood pressure elevation [16-20]. Panic disorder and pseudopheochromocytoma share similar physical symptoms, and both respond to treatment with an antidepressant agent. As mentioned above, panic disorder is present in as many as 40 percent of patients evaluated for pseudopheochromocytoma, | ||
However, the two disorders differ from each other in that the presentation of pseudopheochromocytoma is dominated by autonomic manifestations (ie, paroxysmal hypertension). In patients with pseudopheochromocytoma, fear occurs only in response to the physical symptoms. By contrast, panic disorder is dominated by emotional manifestations (ie, panic), and accompanying blood pressure changes are milder. | However, the two disorders differ from each other in that the presentation of pseudopheochromocytoma is dominated by autonomic manifestations (ie, paroxysmal hypertension). In patients with pseudopheochromocytoma, fear occurs only in response to the physical symptoms. By contrast, panic disorder is dominated by emotional manifestations (ie, panic), and accompanying blood pressure changes are milder. | ||
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Other causes of paroxysmal hypertension — Many additional disorders may present with paroxysmal hypertension, including the following: | Other causes of paroxysmal hypertension — Many additional disorders may present with paroxysmal hypertension, including the following: | ||
●Hyperthyroidism.<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>: symptoms of hyperthyroidism include weight loss, heat intolerance, tremor, palpitations, anxiety, increased bowel disturbances , and shortness of breath. Goiter, skin flushing and eye proptosis are common clinical findings. | |||
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> low thyroid-stimulating hormone (TSH) high free thyroxine (T4) and triiodothyronine (T3) concentrations.In patients with subclinical hyperthyroidism, TSH is below normal (but usually >0.05 mU/L)and serum free T4, T3, and free T3 are normal. | |||
●migraine headaches | |||
●Coronary insufficiency. | ●Coronary insufficiency. | ||
●Renovascular hypertension | ●Renovascular hypertension . | ||
●Central nervous system lesions, such as stroke, tumor, hemorrhage, compression of lateral medulla, and trauma | ●Central nervous system lesions, such as stroke, tumor, hemorrhage, compression of lateral medulla, and trauma | ||
●Seizure disorder. | ●Seizure disorder. | ||
●Carcinoid | ●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 | ||
CLINICAL FEATURES Cutaneous flushing Venous telangiectasia Diarrhea Bronchospasm Cardiac valvular lesions : tricusped incompitence. | |||
* 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> | |||
* Urinary excretion of serotonin <ref name="pmid2421946">{{cite journal| author=Feldman JM| title=Urinary serotonin in the diagnosis of carcinoid tumors. | journal=Clin Chem | year= 1986 | volume= 32 | issue= 5 | pages= 840-4 | pmid=2421946 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2421946 }}</ref> | |||
* Chromogranin concentration Chromogranins (designated as A, B, and C) are proteins that are stored and released with peptides and amines in a variety of neuroendocrine tissues <ref name="pmid2316306">{{cite journal| author=Eriksson B, Arnberg H, Oberg K, Hellman U, Lundqvist G, Wernstedt C et al.| title=A polyclonal antiserum against chromogranin A and B--a new sensitive marker for neuroendocrine tumours. | journal=Acta Endocrinol (Copenh) | year= 1990 | volume= 122 | issue= 2 | pages= 145-55 | pmid=2316306 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2316306 }}</ref> | |||
* Blood serotonin concentration | |||
* Plasma 5-HIAA concentration | |||
CT is recommended for evaluation of all patients with carcinoid tumors <ref name="pmid19077417">{{cite journal| author=Sundin A, Vullierme MP, Kaltsas G, Plöckinger U, Mallorca Consensus Conference participants. European Neuroendocrine Tumor Society| title=ENETS Consensus Guidelines for the Standards of Care in Neuroendocrine Tumors: radiological examinations. | journal=Neuroendocrinology | year= 2009 | volume= 90 | issue= 2 | pages= 167-83 | pmid=19077417 | doi=10.1159/000184855 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19077417 }}</ref> | |||
●Drugs – cocaine, lysergic acid diethylamide, amphetamine, and clozapine [22]. Sympathomimetic drugs that can induce symptoms simulating pheochromocytoma include high-dose phenylpropanolamine (a popular over-the-counter decongestant and appetite suppressant), cocaine, amphetamines, phencyclidine, epinephrine, phenylephrine, and terbutaline, and the combination of a monoamine oxidase (MAO) inhibitor and ingestion of tyramine-containing foods [7,26-29]. Mercury intoxication also can mimic pheochromocytoma, producing both hypertension and elevated urine and plasma catecholamines [30]. | |||
●Baroreflex failure, which is characterized by marked and frequent fluctuations in blood pressure, with both high and low readings [23]. It is caused by hypofunctioning of the 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. | ●Baroreflex failure, which is characterized by marked and frequent fluctuations in blood pressure, with both high and low readings [23]. It is caused by hypofunctioning of the 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. | ||
{{Reflist|2}} | {{Reflist|2}} | ||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ahmad Al Maradni, M.D. [2]
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, Insulinoma, Renovascular hypertension, Hypoglycemia and drugs.
DIFFERENTIAL DIAGNOSIS — In addition to pseudopheochromocytoma, the following diagnoses should be strongly considered among patients presenting with paroxysmal hypertension:
●Pheochromocytoma
●Labile hypertension
●Panic disorder Panic disorder can replicate many of the symptoms of pheochromocytoma because it is associated with increased sympathetic activity. Hypertension in these patients occurs primarily during treatment with a tricyclic antidepressant drug, which may increase the degree of sympathetic arousal.
Pheochromocytoma — The diagnosis of pheochromocytoma must be excluded in all patients with unprovoked paroxysmal hypertension. Assays of plasma or urine catecholamines are diagnostic in 95 percent of patients with symptoms, and the high sensitivity of the plasma metanephrine assay is also documented
pseudopheochromocytoma insist that the disorder is unrelated to psychologic factors.
Panic disorder — Panic disorder is characterized by episodes of fear or panic, and is commonly associated with physical symptoms such as chest pain, headache, palpitations, flushing, and dizziness, along with some degree of blood pressure elevation [16-20]. Panic disorder and pseudopheochromocytoma share similar physical symptoms, and both respond to treatment with an antidepressant agent. As mentioned above, panic disorder is present in as many as 40 percent of patients evaluated for pseudopheochromocytoma,
However, the two disorders differ from each other in that the presentation of pseudopheochromocytoma is dominated by autonomic manifestations (ie, paroxysmal hypertension). In patients with pseudopheochromocytoma, fear occurs only in response to the physical symptoms. By contrast, panic disorder is dominated by emotional manifestations (ie, panic), and accompanying blood pressure changes are milder.
The most critical clinical difference is that, in the absence of antecedent panic or emotional distress, pseudopheochromocytoma is viewed as an unexplained medical disorder. Therefore, clinicians and patients rarely consider an emotion-based cause or treatment because, by definition, patients fail to report any triggering emotional distress.
Other causes of paroxysmal hypertension — Many additional disorders may present with paroxysmal hypertension, including the following:
●Hyperthyroidism.[1]: symptoms of hyperthyroidism include weight loss, heat intolerance, tremor, palpitations, anxiety, increased bowel disturbances , and shortness of breath. Goiter, skin flushing and eye proptosis are common clinical findings.
Increased sensitivity of beta receptors in heart to catecholamines [2] due to effect of thyroid hormones increase cardiac work and output and systolic hypertension.[3] low thyroid-stimulating hormone (TSH) high free thyroxine (T4) and triiodothyronine (T3) concentrations.In patients with subclinical hyperthyroidism, TSH is below normal (but usually >0.05 mU/L)and serum free T4, T3, and free T3 are normal.
●migraine headaches
●Coronary insufficiency.
●Renovascular hypertension .
●Central nervous system lesions, such as stroke, tumor, hemorrhage, compression of lateral medulla, and trauma
●Seizure disorder.
●Carcinoid syndrome: hypertensive crisis occurs with malignant carcinoid syndrome [4] should be distinguished from pheochromocytoma. Patient
CLINICAL FEATURES Cutaneous flushing Venous telangiectasia Diarrhea Bronchospasm Cardiac valvular lesions : tricusped incompitence.
- Urinary excretion of 5-HIAA [5]
- Urinary excretion of serotonin [6]
- Chromogranin concentration Chromogranins (designated as A, B, and C) are proteins that are stored and released with peptides and amines in a variety of neuroendocrine tissues [7]
- Blood serotonin concentration
- Plasma 5-HIAA concentration
CT is recommended for evaluation of all patients with carcinoid tumors [8]
●Drugs – cocaine, lysergic acid diethylamide, amphetamine, and clozapine [22]. Sympathomimetic drugs that can induce symptoms simulating pheochromocytoma include high-dose phenylpropanolamine (a popular over-the-counter decongestant and appetite suppressant), cocaine, amphetamines, phencyclidine, epinephrine, phenylephrine, and terbutaline, and the combination of a monoamine oxidase (MAO) inhibitor and ingestion of tyramine-containing foods [7,26-29]. Mercury intoxication also can mimic pheochromocytoma, producing both hypertension and elevated urine and plasma catecholamines [30].
●Baroreflex failure, which is characterized by marked and frequent fluctuations in blood pressure, with both high and low readings [23]. It is caused by hypofunctioning of the 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.
- ↑ 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.
- ↑ 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.