Pheochromocytoma differential diagnosis

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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] Mohammed Abdelwahed M.D[3]


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, 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. The differentials include:

Disease Symptoms Signs Investigations
Pheochromocytoma[1][4] Features of sympathetic nervous systemhyperactivity and include:
Pseudopheochromocytoma (idiopathic)[1][2][3][4] Paroxysmal activation of the sympathetic system may cause:
Panic attacks

Laboratory studies that can exclude medical disorders other than panic disorder include:

Labile hypertension (White coat hypertension) Elevated blood pressure, tachycardia, and may be anxiety in a clinical setting but not in other settings[1]
Renovascular hypertension
Stroke and compression of lateral medulla (Lateral medullary syndrome)
  • Difficulty sitting upright without support
  • Hypotonia of the ipsilateral arm
  • Ipsilateral decreased pain and temperature sensation in the face
  • The corneal reflex is usually reduced in the ipsilateral eye
  • Contralateral loss of pain and thermal sensation involving the body and limbs
Seizures According to type; it may be focal or generalized, clinical or subclinical:[7]
  • Tonic-clonic seizure:
    • Repetitive twitches of arm and legs
    • Tongue bitting
    • Loss of consciousness
    • Symptoms occur suddenly and may persist
    • Muscle tension or tightening that causes twisting of the body, head, arms, or legs
    • Amnesia
    • Mood changes (fear, panic, or laughter)
    • Change in sensation of the skin over the arm, leg, or trunk
    • Vision changes and light flashes
    • Hallucinations
    • Tasting a bitter or metallic flavor
  • Complex partial seizure:
    • Confused or dazed and
    • Not be able to respond to questions or direction
  • Absence seizure:
    • Rapid blinking
    • Few seconds of staring into space
Carcinoid syndrome Hypertensive crisis occurs with malignant carcinoid syndrome[10]. Symptoms include:
Migraine headaches
  • Prodrome:
  • Pain phase
  • Postdrome phase[15]
CT is indicated in patients with:[1][2]

CT is not indicated in:

Drugs Sympathomimetic drugs that can induce symptoms simulating pheochromocytoma include:
Baroreflex failure[18]
  • Baroreflex failure patients show a normal or even an increased pressor response to cold-pressor and handgrip testing. These responses are attenuated in patients with autonomic failure.
  • Neck CT scan

Pheochromocytoma must be differentiated from other adrenal tumors such as adrenocortical adenoma, adrenal metastasis, and Cushing's syndrome.

Differential Diagnosis Clinical picture Imagings Laboratory tests
Adrenocortical carcinoma
Adrenal adenoma
Cushing's syndrome
  • Imaging may show mass if presents
Adrenal metastasis


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