Paroxysmal hypertension (pseudopheochromocytoma)
- Samuel J Mann, MD
Samuel J Mann, MD
- Professor of Clinical Medicine
- Division of Nephrology and Hypertension
- NY Presbyterian Hospital – Weill Cornell Medical College
The presence of severe and symptomatic paroxysmal hypertension should always generate suspicion of a catecholamine-secreting pheochromocytoma . However, the reality is that this tumor is rarely found among such patients . In one report, the diagnosis was established in only 1 of 300 patients evaluated for pheochromocytoma . Up to 40 percent of patients in this series fulfilled the criteria for panic disorder.
In most patients with paroxysmal hypertension and a negative evaluation for pheochromocytoma, the cause remains unknown, treatment is difficult, and many incur chronic disability. This clinical constellation is sometimes called "pseudopheochromocytoma" . A paucity of data concerning the clinical characteristics of this disorder exists.
The proposed cause, clinical features (including link to emotions), differential diagnosis, and management of pseudopheochromocytoma will be reviewed here. The diagnosis and treatment of pheochromocytoma and panic disorder are presented separately. (See "Clinical presentation and diagnosis of pheochromocytoma" and "Treatment of pheochromocytoma in adults" and "Pharmacotherapy for panic disorder in adults".)
Pseudopheochromocytoma most likely involves activation of the sympathetic system; this has been inferred from the following observations [5-11]:
- Manger WM, Gifford RW. Pheochromocytoma: A clinical overview. In: Hypertension: Pathophysiology, Diagnosis, and Management, 2nd ed, Laragh JH, Brenner BM (Eds), Raven Press, Ltd, New York City 1995.
- Pacak K, Linehan WM, Eisenhofer G, et al. Recent advances in genetics, diagnosis, localization, and treatment of pheochromocytoma. Ann Intern Med 2001; 134:315.
- Fogarty J, Engel C, Russo J, et al. Hypertension and pheochromocytoma testing: The association with anxiety disorders. Arch Fam Med 1994; 3:55.
- Kuchel O. Pseudopheochromocytoma. Hypertension 1985; 7:151.
- Mann SJ. Severe paroxysmal hypertension. An automatic syndrome and its relationship to repressed emotions. Psychosomatics 1996; 37:444.
- Kuchel O, Buu NT, Hamet P, et al. Dopamine surges in hyperadrenergic essential hypertension. Hypertension 1982; 4:845.
- Hamada M, Shigematsu Y, Mukai M, et al. Blood pressure response to the Valsalva maneuver in pheochromocytoma and pseudopheochromocytoma. Hypertension 1995; 25:266.
- Mann SJ. Severe paroxysmal hypertension (pseudopheochromocytoma): understanding the cause and treatment. Arch Intern Med 1999; 159:670.
- Sharabi Y, Goldstein DS, Bentho O, et al. Sympathoadrenal function in patients with paroxysmal hypertension: pseudopheochromocytoma. J Hypertens 2007; 25:2286.
- Mackenzie IS, Brown MJ. Pseudopheochromocytoma. J Hypertens 2007; 25:2204.
- Hunt J, Lin J. Paroxysmal hypertension in a 48-year-old woman. Kidney Int 2008; 74:532.
- Raber W, Raffesberg W, Bischof M, et al. Diagnostic efficacy of unconjugated plasma metanephrines for the detection of pheochromocytoma. Arch Intern Med 2000; 160:2957.
- Lenders JW, Pacak K, Walther MM, et al. Biochemical diagnosis of pheochromocytoma: which test is best? JAMA 2002; 287:1427.
- Hickman PE, Leong M, Chang J, et al. Plasma free metanephrines are superior to urine and plasma catecholamines and urine catecholamine metabolites for the investigation of phaeochromocytoma. Pathology 2009; 41:173.
- Bravo EL. Evolving concepts in the pathophysiology, diagnosis, and treatment of pheochromocytoma. Endocr Rev 1994; 15:356.
- Balon R, Ortiz A, Pohl R, Yeragani VK. Heart rate and blood pressure during placebo-associated panic attacks. Psychosom Med 1988; 50:434.
- Liebowitz MR, Gorman JM, Fyer AJ, et al. Lactate provocation of panic attacks. II. Biochemical and physiological findings. Arch Gen Psychiatry 1985; 42:709.
- Cameron OG, Lee MA, Curtis GC, McCann DS. Endocrine and physiological changes during "spontaneous" panic attacks. Psychoneuroendocrinology 1987; 12:321.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders IV, 8th ed, Washington, DC 1994.
- Katon W, Roy-Byrne PP. Panic disorder in the medically ill. J Clin Psychiatry 1989; 50:299.
- White WB, Baker LH. Episodic hypertension secondary to panic disorder. Arch Intern Med 1986; 146:1129.
- Krentz AJ, Mikhail S, Cantrell P, Hill GM. Drug Points: Pseudophaeochromocytoma syndrome associated with clozapine. BMJ 2001; 322:1213.
- Zar T, Peixoto AJ. Paroxysmal hypertension due to baroreflex failure. Kidney Int 2008; 74:126.
- Mann SJ. Severe paroxysmal hypertension (pseudopheochromocytoma). Curr Hypertens Rep 2008; 10:12.
- Vaclavik J, Krenkova A, Kocianova E, et al. 7B.04: EFFECT OF SERTRALINE IN PAROXYSMAL HYPERTENSION. J Hypertens 2015; 33 Suppl 1:e93.
- CLINICAL MANIFESTATIONS
- Psychological characteristics
- DIFFERENTIAL DIAGNOSIS
- Labile hypertension
- Panic disorder
- Other causes of paroxysmal hypertension
- Antihypertensive agents
- - Acute management of paroxysms
- - Chronic preventive management
- Psychopharmacologic agents
- Psychotherapeutic intervention
- Obstacles to successful treatment
- SUMMARY AND RECOMMENDATIONS