Inpatient Measurements of Urine Metanephrines are Indistinguishable from Pheochromocytoma: Retrospective Cohort Study

Kline, Gregory; Boyd, Jessica M.; Sadrzadeh, Hossein; Leung, Alexander A. C.

doi:10.1016/j.amjmed.2021.03.015

Cited by 10 publications

(3 citation statements)

References 36 publications

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“…No cut-off values of metanephrines have been established to distinguish between the two clinical situations. Kline et al showed a significant overlap of urinary metanephrine testing in critically ill patients and patients with diagnosed pheochromocytoma (particularly urinary normetanephrine), with increased specificity being achieved when levels were above 5× the upper limit, although still not achieving strong predictive values ( 6 ). Thus, early imaging should be pursued in critically ill patients to establish or rule out the presence of a pheochromocytoma, which will help in changing the pretest probability and guide appropriate treatment ( 7 ).…”

Section: Discussionmentioning

confidence: 99%

Acute heart failure with incidentally found cystic adrenal mass

Bhat,

Hamrahian,

et al. 2023

Endocrinology, Diabetes &Amp; Metabolism Case Reports

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Summary Pheochromocytomas are rare adrenal tumors characterized by excessive catecholamine secretion. Symptoms and signs associated with pheochromocytomas are usually intermittent and chronic but can rarely develop into life-threatening crises. We describe a case of acute severe congestive heart failure in a previously healthy female, who recovered rapidly (4 days after admission) with acute medical therapy. The etiology on evaluation was a spontaneous bleed in a previously undiagnosed pheochromocytoma, resulting in a pheochromocytoma crisis and transient stress cardiomyopathy, followed by quick recovery of cardiac function. Our aim is to describe pheochromocytoma as a rare cause of stress cardiomyopathy. We discuss the evaluation of pheochromocytoma during critical illness and triggers/treatment strategies for pheochromocytoma crises. Learning points Hemorrhage in a pheochromocytoma can result in a pheochromocytoma crisis, with sudden release of excess catecholamines resulting in multisystem organ dysfunction and high mortality. Acute decompensated heart failure can be a rare presentation of pheochromocytoma, in a patient with no cardiac risk factors. Measurement of metanephrines in acutely stressful clinical situations can have considerable overlap with the biochemical picture of pheochromocytoma. Early imaging studies may help with the differential diagnosis. Pheochromocytoma should be ruled out before performing an adrenal biopsy. Emergent adrenalectomy in pheochromocytoma crisis results in high mortality. Medical management of the acute crisis followed by elective adrenalectomy after alpha-blockade results in better outcomes.

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Section: Discussionmentioning

confidence: 99%

Acute heart failure with incidentally found cystic adrenal mass

Bhat,

Hamrahian,

et al. 2023

Endocrinology, Diabetes &Amp; Metabolism Case Reports

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“…In the critical care setting, the interpretation of catecholamines is more challenging due to the use of adrenergic agents as well as endogenous (physiological) release. A retrospective study comparing urine metanephrine levels from inpatient patients (including 132 patients from ICU) without pheochromocytoma with those with confirmed pheochromocytoma showed that there was a significant overlap of urine normetanephrine and metanephrine levels between hospitalised patients and patients with pheochromocytoma ( 6 ). The study concluded that for, ICU patients, cathecholamine levels more than five-fold above the upper reference limit had 98% specificity for the diagnosis of pheochromocytoma, but still had poor positive predictive value.…”

Section: Discussionmentioning

confidence: 99%

Case Report: Early Resection of Pheochromocytoma in a Patient With Cardiogenic Shock Due to Pheochromocytoma-Induced Cardiomyopathy With Extracorporeal Life Support

Lyu

Niu

Liu

et al. 2022

Front. Cardiovasc. Med.

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BackgroundPheochromocytoma-induced cardiomyopathy is a rare but potentially life-threatening complication of pheochromocytoma. It mimics the patterns of stress-induced cardiomyopathy. In severe cases, patients can develop refractory cardiogenic shock, which might require mechanical circulatory support.Case PresentationWe presented a case of 54-year-old female who developed refractory cardiogenic shock, following an elective orthopaedic surgery complicated by cardiac arrest, requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support. After urgent coronary catheterisation revealed normal coronary arteries, further evaluation of the aetiology of cardiogenic shock revealed pheochromocytoma. With a diagnosis of pheochromocytoma-induced cardiomyopathy, the patient had accelerated preoperative alpha adrenergic blockade preparation for a total of 6 days and subsequently had the tumour removed under VA-ECMO support. Postoperatively, the patient recovered well and was off ECMO support and extubated a few days later.The optimal management of pheochromocytoma-induced cardiomyopathy, especially for severe cases, is still unclear. Indeed, some cases will require mechanical circulatory support to allow left ventricular function recovery. But our case also showed that it was possible to introduce alpha blockade safely whilst the patient is on VA-ECMO and has the pheochromocytoma removed with VA-ECMO support after accelerated preoperative preparation.

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“…For both plasma and urinary measurements, it is important that samples are procured with patients under conditions of minimal physiological or emotional distress ( Figure 5 ). In adults it is well established that emergency situations and acute illness can result in plasma concentrations or urinary outputs of metanephrines that can be indistinguishable from those in patients with catecholamine-producing tumors ( 73 ). The same can also be expected for children, so that ideally testing for a catecholamine-producing tumor should be undertaken after recovery from a hypertensive emergency or severe illness.…”

Section: Preanalytical Considerationsmentioning

confidence: 99%

Biochemical Diagnosis of Catecholamine-Producing Tumors of Childhood: Neuroblastoma, Pheochromocytoma and Paraganglioma

et al. 2022

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Catecholamine-producing tumors of childhood include most notably neuroblastoma, but also pheochromocytoma and paraganglioma (PPGL). Diagnosis of the former depends largely on biopsy-dependent histopathology, but this is contraindicated in PPGL where diagnosis depends crucially on biochemical tests of catecholamine excess. Such tests retain some importance in neuroblastoma though continue to largely rely on measurements of homovanillic acid (HVA) and vanillylmandelic acid (VMA), which are no longer recommended for PPGL. For PPGL, urinary or plasma metanephrines are the recommended most accurate tests. Addition of methoxytyramine to the plasma panel is particularly useful to identify dopamine-producing tumors and combined with normetanephrine also shows superior diagnostic performance over HVA and VMA for neuroblastoma. While use of metanephrines and methoxytyramine for diagnosis of PPGL in adults is established, there are numerous pitfalls for use of these tests in children. The establishment of pediatric reference intervals is particularly difficult and complicated by dynamic changes in metabolites during childhood, especially in infants for both plasma and urinary measurements, and extending to adolescence for urinary measurements. Interpretation of test results is further complicated in children by difficulties in following recommended preanalytical precautions. Due to this, the slow growing nature of PPGL and neglected consideration of the tumors in childhood the true pediatric prevalence of PPGL is likely underappreciated. Earlier identification of disease, as facilitated by surveillance programs, may uncover the true prevalence and improve therapeutic outcomes of childhood PPGL. For neuroblastoma there remain considerable obstacles in moving from entrenched to more accurate tests of catecholamine excess.

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Inpatient Measurements of Urine Metanephrines are Indistinguishable from Pheochromocytoma: Retrospective Cohort Study

Cited by 10 publications

References 36 publications

Acute heart failure with incidentally found cystic adrenal mass

Acute heart failure with incidentally found cystic adrenal mass

Case Report: Early Resection of Pheochromocytoma in a Patient With Cardiogenic Shock Due to Pheochromocytoma-Induced Cardiomyopathy With Extracorporeal Life Support

Biochemical Diagnosis of Catecholamine-Producing Tumors of Childhood: Neuroblastoma, Pheochromocytoma and Paraganglioma

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