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Clarifying the Cause and Treatment of Paroxysmal Hypertension (Pseudopheochromocytoma). Curr Hypertens Rep 2022; 24:353-359. [PMID: 35666406 DOI: 10.1007/s11906-022-01198-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW To review the clinical characteristics of paroxysmal hypertension (pseudopheochromocytoma), its previously unsuspected cause, and effective treatment approaches. RECENT FINDINGS Patients with paroxysmal hypertension experience recurrent, sudden, unprovoked, symptomatic, and severe elevations of blood pressure that occur independently of current stress or perceived emotional distress. Recent findings point to a previously unsuspected psychosomatic etiology, linked in most to a past history of abuse, trauma, or prolonged severe stress, often with repression of pertinent emotions, or to a repressive coping style. Consistent with this understanding, treatment with an antidepressant is thus far the only pharmacologic intervention demonstrated to be effective in preventing recurrent paroxysms, and is effective in most patients. Other treatment approaches are discussed, including medications to acutely lower blood pressure during paroxysms, and, in some cases, the possibility of emotional healing. Recent findings indicate that paroxysmal hypertension is a psychosomatic disorder frequently linked to a past history of trauma or prolonged severe stress, usually with longstanding repression of pertinent emotions. Data strongly encourage treatment with an antidepressant in patients with recurrent or severe paroxysms. Further studies are needed.
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Brook I, Cohen E, Stemer A. Correction of carotid artery stenosis by stent placement ameliorated paroxysmal hypertension after radiation treatment of hypopharyngeal carcinoma: a case report. J Med Case Rep 2022; 16:70. [PMID: 35172903 PMCID: PMC8851753 DOI: 10.1186/s13256-022-03293-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 01/24/2022] [Indexed: 11/17/2022] Open
Abstract
Background Paroxysmal hypertension can be associated with failure of the carotid artery baroreceptors due to past exposure to radiation treatment. This report describes a patient whose repeated paroxysmal hypertensive episodes were ameliorated following placement of a carotid artery stent for the treatment of carotid artery stenosis. Case report A 79-year-old caucasian male was diagnosed with hypopharyngeal squamous cell carcinoma (T1, L0, M0) in 2006, and received 70 Gy intensity-modulated radiotherapy in 2006 and underwent a total laryngectomy in 2008. He experienced paroxysmal hypertensive episodes since 2010 that exacerbated in frequency in 2019. Eighty percent left internal carotid artery stenosis was demonstrated by ultrasound and arteriography. Angioplasty and stenting of the left carotid artery was performed. A Doppler ultrasound study performed 5 months after the stent placement did not reveal any hemodynamic stenosis in the left carotid artery. The patient experienced postprandial hypotension and had experienced only three episodes of paroxysmal hypertension in the following 24 months. He was able to abort paroxysmal hypertensive episodes by eating warm food. Discussion This is the first report of a patient whose paroxysmal hypertensive episodes that occurred following radiation of the neck subsided after placement of a stent in a stenotic carotid artery. The exact mechanism leading to this phenomena is unknown but may be due to several factors. The reversal of the carotid artery stent and improvement in blood flow to the carotid artery baroceptors may play a role in this phenomenon. Conclusion The ability to ameliorate paroxysmal hypertensive episodes in a patient with carotid artery stenosis by stent placement may be a promising therapeutic intervention for paroxysmal hypertension.
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Affiliation(s)
- Itzhak Brook
- Departments of Pediatrics, Georgetown University School of Medicine, Washington DC, 4431 Albemarle St NW, Washington DC, 20016, USA.
| | - Ezra Cohen
- The Neurology Center, Washington DC, USA
| | - Andrew Stemer
- Departments of Neurology, Georgetown University School of Medicine, Washington DC, USA
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Turin CG, Cohen DL. Pseudopheochromocytoma: an Uncommon Cause of Severe Hypertension. Curr Cardiol Rep 2022; 24:59-64. [PMID: 35000148 DOI: 10.1007/s11886-021-01624-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/30/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Pseudopheochromocytoma or paroxysmal hypertension is an underrecognized condition that requires a thorough investigation of secondary causes of hypertension. In this review, we aim to provide an overview of pathogenesis, clinical manifestations, biochemical evaluation, and potential therapeutic options to manage patients with pseudopheochromocytoma. RECENT FINDINGS The pathogenesis of this condition has not been completely elucidated but certain patients show overactivity of the sympathetic nervous system and present with elevated epinephrine and dopamine levels. Workup should include a proper evaluation of blood pressure in distinct clinical scenarios, including ambulatory blood pressure monitoring. Management should be focused on treatment of acute hypertensive episodes and prevention of paroxysms. Treatment of patients with pseudopheochromocytoma should be individualized. Psychopharmacotherapy and psychotherapeutic interventions play an important role in controlling patients' symptoms.
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Affiliation(s)
- Christie G Turin
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Debbie L Cohen
- Renal Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, 1 Founders Building, 3400 Spruce Street, Philadelphia, PA, 19104, USA.
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Brook I. Paroxysmal Hypertensive Episodes Caused by Direct Massage of the Carotid Artery by a Doppler Ultrasound of the Neck in a Laryngectomee. J Med Ultrasound 2020; 28:114-116. [PMID: 32874871 PMCID: PMC7446695 DOI: 10.4103/jmu.jmu_77_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 10/08/2019] [Accepted: 10/14/2019] [Indexed: 12/02/2022] Open
Abstract
Paroxysmal hypertension (PH) can be associated with the carotid artery baroreceptors' failure due to past exposure to radiation treatment. This report presents a patient who experienced repeated PH episodes due to the direct massage of the carotid artery during Doppler ultrasound of the neck. The radiation damage to the carotid artery baroreceptors might have increased their hypersensitivity to the mechanical and ultrasonic stimulation during the diagnostic test, leading to the hypertensive episodes. Patients who had received radiation therapy for head-and-neck cancer and require Doppler ultrasound of the carotid artery should be monitored for PH by recording their blood pressure prior and after the test.
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Affiliation(s)
- Itzhak Brook
- Department of Pediatrics and Medicine, Georgetown University School of Medicine, Washington, DC, USA
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5
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The Japanese Society of Hypertension Guidelines for the Management of Hypertension (JSH 2019). Hypertens Res 2020; 42:1235-1481. [PMID: 31375757 DOI: 10.1038/s41440-019-0284-9] [Citation(s) in RCA: 976] [Impact Index Per Article: 244.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Dyer K, Vettese TE. Unexplained Symptomatic Paroxysmal Hypertension: a Diagnostic and Management Challenge. J Gen Intern Med 2020; 35:586-589. [PMID: 31705462 PMCID: PMC7018868 DOI: 10.1007/s11606-019-05503-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 05/31/2019] [Accepted: 10/10/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Kelly Dyer
- Emory University School of Medicine, Atlanta, GA, USA.
| | - Theresa E Vettese
- Division of General Medicine and Geriatrics, Department of Medicine, Emory University School of Medicine, Atlanta, USA
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7
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Abstract
Pseudopheochromocytoma manifests as severe, symptomatic paroxysmal hypertension without significant elevation in catecholamine and metanephrine levels and lack of evidence of tumor in the adrenal gland. The clinical manifestations are similar but not identical to those in excess circulating catecholamines. The underlying symptomatic mechanism includes augmented cardiovascular responsiveness to catecholamines alongside heightened sympathetic nervous stimulation. The psychological characteristics are probably attributed to the component of repressed emotions related to a past traumatic episode or repressive coping style. Successful management can be achieved by strong collaboration between a hypertension specialist and a psychiatrist or psychologist with expertise in cognitive-behavioral panic management.
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Affiliation(s)
- Divya Mamilla
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, 10 Center Drive, Bethesda, MD 20892, USA
| | - Melissa K Gonzales
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, 10 Center Drive, Bethesda, MD 20892, USA
| | - Murray D Esler
- Baker IDI Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia; Dobney Hypertension Centre, Royal Perth Hospital Campus, University of Western Australia, Rear 50 Murray St, Perth, WA 6000, Australia
| | - Karel Pacak
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver NICHD, NIH, Building 10, CRC, 1E-3140, 10 Center Drive, MSC-1109, Bethesda, MD 20892-1109, USA.
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Labile hypertension: a new disease or a variability phenomenon? J Hum Hypertens 2019; 33:436-443. [PMID: 30647464 DOI: 10.1038/s41371-018-0157-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 11/03/2018] [Accepted: 12/17/2018] [Indexed: 11/08/2022]
Abstract
Blood pressure (BP) is a physiological parameter with short- and long-term variability caused by complex interactions between intrinsic cardiovascular (CV) mechanisms and extrinsic environmental and behavioral factors. Available evidence suggests that not only mean BP values are important, but also BP variability (BPV) might contribute to CV events. Labile hypertension (HTN) is referred to sudden rises in BP and it seems to be linked with unfavorable outcomes. The aim of this article was to review and summarize recent evidence on BPV phenomenon, unraveling the labile HTN concept along with the prognostic value of these conditions.
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Brook I. Paroxysmal hypertensive episodes caused by direct massage of the carotid artery by a doppler ultrasound of the neck in a laryngectomee. J Med Ultrasound 2019. [DOI: 10.4103/0929-6441.274112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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10
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Un pseudophéochromocytome induit par le stress professionnel ; à propos d’un cas. Rev Med Interne 2018; 39:879-881. [DOI: 10.1016/j.revmed.2018.03.377] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 03/16/2018] [Accepted: 03/23/2018] [Indexed: 11/17/2022]
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Brook I. The challenges of treating tracheobronchitis in a laryngectomee due to nontypeable Haemophilus influenzae: a case report. J Med Case Rep 2018; 12:242. [PMID: 30124173 PMCID: PMC6100715 DOI: 10.1186/s13256-018-1764-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 07/07/2018] [Indexed: 11/24/2022] Open
Abstract
Background Laryngectomees run the risk of developing severe respiratory tract infections especially during the winter and when they do not wear a stoma cover. A case of severe tracheobronchitis in a laryngectomee is presented that illustrates the risks and difficulties encountered in managing this infection in a neck breather. Case presentation A 76-year-old Caucasian man, a laryngectomee, presented with bacterial tracheobronchitis and conjunctivitis due to beta-lactamase-producing nontypeable Haemophilus influenzae. He was febrile (38.9 °C; 102.0 F), and had repeated episodes of hypertension. He was treated with levofloxacin 500 mg/day, ciprofloxacin eye drops, acetaminophen, and guaifenesin. Humidification of his trachea and the airway was sustained by insertions of saline into the stoma as well as breathing humidified air. The main challenge was to maintain the patency of his airway as the mucus was very dry and viscous and tended to stick to the walls of his trachea and the stoma. His condition improved within 7 days and he had a complete recovery. Conclusions Maintaining the patency of the airway in laryngectomees who suffer from lower respiratory tract infection is of utmost importance as the mucus can be very dry and viscous and can stick to the walls of the trachea and the stoma.
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Affiliation(s)
- Itzhak Brook
- Department of Pediatrics and Medicine, Georgetown University School of Medicine, Washington DC, 20007, USA.
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12
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Mann SJ. Neurogenic hypertension: pathophysiology, diagnosis and management. Clin Auton Res 2018; 28:363-374. [DOI: 10.1007/s10286-018-0541-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 06/19/2018] [Indexed: 02/07/2023]
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Vaclavik J, Krenkova A, Kocianova E, Vaclavik T, Kamasova M. Effect of sertraline in paroxysmal hypertension. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2018; 162:116-120. [DOI: 10.5507/bp.2017.039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 09/06/2017] [Indexed: 11/23/2022] Open
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Le HM, Carbutti G, Ilisei D, Bouccin E, Vandemergel X. Pseudopheochromocytoma Associated with Domestic Assault. Case Rep Cardiol 2016; 2016:6580215. [PMID: 27738531 PMCID: PMC5050350 DOI: 10.1155/2016/6580215] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 08/28/2016] [Indexed: 01/19/2023] Open
Abstract
Pseudopheochromocytoma has a clinical presentation that is similar to pheochromocytoma. It manifests itself with paroxysmal hypertension crises, associated with various symptoms such as headaches, chest pain, nausea, palpitations, and dizziness. Patients are usually asymptomatic in between the crises. Unlike pheochromocytoma, there is no catecholamines overproduction in this pathology: hypertensive peaks are caused by a hyperactivation of the sympathetic nervous system, which is often triggered by a psychological trauma in the past. Treatment of pseudopheochromocytoma can be challenging due to normal blood pressure values in between the hypertensive peaks; it includes alpha- and beta-blockers for moderate crises and prevention and must be combined with psychopharmacologic agents such as anxiolytics or antidepressant drugs. Psychotherapy and dietetic treatment are also crucial in pseudopheochromocytoma management.
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Affiliation(s)
- H. M. Le
- Department of General Internal Medicine, Centres Hospitaliers Jolimont, Nivelles, Belgium
| | - G. Carbutti
- Intensive Care Unit, Centres Hospitaliers Jolimont, Nivelles, Belgium
| | - D. Ilisei
- Department of General Internal Medicine, Centres Hospitaliers Jolimont, Nivelles, Belgium
| | - E. Bouccin
- Intensive Care Unit, Centres Hospitaliers Jolimont, Nivelles, Belgium
| | - X. Vandemergel
- Intensive Care Unit, Centres Hospitaliers Jolimont, Nivelles, Belgium
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Abstract
Although "labile hypertension" is regularly encountered by clinicians, there is a paucity of information available to guide therapeutic decisions. This review discusses its clinical relevance, the limitations of current knowledge, and possible directions for future research and clinical management. Results of studies that assessed measures of blood pressure variability or reactivity are reviewed. The limited information about effects of antihypertensive drugs on blood pressure variability is discussed. Two different clinical presentations are differentiated: labile hypertension and paroxysmal hypertension. Labile hypertension remains a clinical impression without defined criteria or treatment guidance. Paroxysmal hypertension, also called pseudopheochromocytoma, presents as dramatic episodes of abrupt and severe blood pressure elevation. The disorder can be disabling. Although it regularly raises suspicion of a pheochromocytoma, such a tumor is found in <2 % of patients. The cause, which involves both emotional factors and the sympathetic nervous system, and treatment approaches, are presented.
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Affiliation(s)
- Samuel J Mann
- Division of Nephrology and Hypertension, NY-Presbyterian Hospital-Weill Cornell Medical College, 424 East 70th St, New York, NY, 10021, USA.
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López-Sánchez G, Reyna-Villasmil E. Seudofeocromocitoma causado por clozapina. Med Clin (Barc) 2016; 146:562-3. [DOI: 10.1016/j.medcli.2015.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 12/14/2015] [Accepted: 12/17/2015] [Indexed: 10/22/2022]
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Marmouch H, Arfa S, Graja S, Slim T, Khochtali I. Obstructive sleep apnea presenting as pseudopheochromocytoma. Pan Afr Med J 2016; 23:75. [PMID: 27217898 PMCID: PMC4862767 DOI: 10.11604/pamj.2016.23.75.8979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 02/18/2016] [Indexed: 11/11/2022] Open
Abstract
A 52-year-old female with a history of poorly controlled resistant hypertension was admitted to our hospital with severe hypertension. She had a history of fatigue and intermittent episodes of palpitations. Laboratory evaluation was significant for elevated 24-h urinary catecholamine levels (3,5 times the upper normal levels). This case was presenting with a clinical and biochemical picture indistinguishable from that of pheochromocytoma. However, neither computed tomography nor meta-iodo-benzyl-guanidine scintigraphy detected any catecholamine-producing tumor in or outside the adrenal glands. Our patient was screened with full polysomnography because of heavy snoring, daytime somnolence and obesity. It revealed severe obstructive sleep apnea syndrome. After three months of continuous positive airway pressure therapy, the patient experienced resolution of his presenting symptoms, improved blood pressure control and normalization of his urinary catecholamine levels. This case highlights sleep disordered breathing as a potentially reversible cause of pseudo-pheochromocytoma.
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Affiliation(s)
- Hela Marmouch
- Department of Endocrinology and Internal Medecine, Fattouma Bourguiba University Hospital, Monastir, Tunisia
| | - Sondes Arfa
- Department of Endocrinology and Internal Medecine, Fattouma Bourguiba University Hospital, Monastir, Tunisia
| | - Sameh Graja
- Department of Endocrinology and Internal Medecine, Fattouma Bourguiba University Hospital, Monastir, Tunisia
| | - Tensim Slim
- Department of Endocrinology and Internal Medecine, Fattouma Bourguiba University Hospital, Monastir, Tunisia
| | - Ines Khochtali
- Department of Endocrinology and Internal Medecine, Fattouma Bourguiba University Hospital, Monastir, Tunisia
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Garcha AS, Cohen DL. Catecholamine excess: pseudopheochromocytoma and beyond. Adv Chronic Kidney Dis 2015; 22:218-23. [PMID: 25908471 DOI: 10.1053/j.ackd.2014.11.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Revised: 11/02/2014] [Accepted: 11/03/2014] [Indexed: 12/21/2022]
Abstract
Symptoms of catecholamine excess or pseudopheochromocytoma can be clinically indistinguishable from pheochromocytoma. Patients usually present with paroxysmal or episodic hypertension and have a negative evaluation for pheochromocytoma. It is important to exclude other causes of catecholamine excess that can be induced by stress, autonomic dysfunction due to baroreflex failure, medications, and drugs. Patients with pseudopheochromocytoma appear to have an amplified cardiovascular responsiveness to catecholamines with enhanced sympathetic nervous stimulation. The exact mechanism is not well understood and increased secretion of dopamine, epinephrine, and norepinephrine, and their metabolites have been identified as potentiating this clinical scenario leading to differing hemodynamic presentations depending on which catecholamine is elevated. Management of this condition is often difficult and frustrating for both the physician and the patient. Most patients respond reasonably well to medications that reduce sympathetic nervous system activity. Anxiolytics, antidepressants, and psychotherapy also play an important role in managing these patients' symptoms.
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Páll A, Becs G, Erdei A, Sira L, Czifra A, Barna S, Kovács P, Páll D, Pfliegler G, Paragh G, Szabó Z. Pseudopheochromocytoma induced by anxiolytic withdrawal. Eur J Med Res 2014; 19:53. [PMID: 25288254 PMCID: PMC4196012 DOI: 10.1186/s40001-014-0053-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 09/22/2014] [Indexed: 11/30/2022] Open
Abstract
Background Symptomatic paroxysmal hypertension without significantly elevated catecholamine concentrations and with no evidence of an underlying adrenal tumor is known as pseudopheochromocytoma. Methods We describe the case of a female patient with paroxysmal hypertensive crises accompanied by headache, vertigo, tachycardia, nausea and altered mental status. Previously, she was treated for a longer period with alprazolam due to panic disorder. Causes of secondary hypertension were excluded. Neurological triggers (intracranial tumor, cerebral vascular lesions, hemorrhage, and epilepsy) could not be detected. Results Setting of the diagnosis of pseudopheochromocytoma treatment was initiated with alpha- and beta-blockers resulting in reduced frequency of symptoms. Alprazolam was restarted at a daily dose of 1 mg. The patient’s clinical condition improved rapidly and the dosage of alpha- and beta-blockers could be decreased. Conclusions We conclude that the withdrawal of an anxiolytic therapeutic regimen may generate sympathetic overdrive resulting in life-threatening paroxysmal malignant hypertension and secondary encephalopathy. We emphasize that pseudopheochromocytoma can be diagnosed only after exclusion of the secondary causes of hypertension. We highlight the importance of a psychopharmacological approach to this clinical entity.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Zoltán Szabó
- Division of Emergency Medicine, Institute of Internal Medicine, University of Debrecen Medical Center, Nagyerdei krt, 98, Debrecen, 4032, Hungary.
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Mazza A, Armigliato M, Marzola MC, Schiavon L, Montemurro D, Vescovo G, Zuin M, Chondrogiannis S, Ravenni R, Opocher G, Colletti PM, Rubello D. Anti-hypertensive treatment in pheochromocytoma and paraganglioma: current management and therapeutic features. Endocrine 2014; 45:469-78. [PMID: 23817839 DOI: 10.1007/s12020-013-0007-y] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 06/21/2013] [Indexed: 02/06/2023]
Abstract
Pheochromocytoma (PH) and paraganglioma (PG) are neuroendocrine neoplasms arising from chromaffin cells of the adrenal medulla and the sympathetic ganglia, respectively. Although are unusual cause of hypertension (HT) accounting for at most 0.1-0.2 % of cases, they may lead to severe and potentially lethal hypertensive crisis due to the effects of the released catecholamines. However, both PH and PG may be asymptomatic as ~30 % of subjects are normotensive or have orthostatic hypotension and in these cases the 24 h ambulatory blood pressure (BP) monitoring is an important toll to diagnose and treat HT. HT treatment may be difficult when PH or PG occurs in pregnancy or in the elderly subjects and in these cases a multidisciplinary team is required. When surgical excision is mandatory the perioperative management requires the administration of selective α1-adrenergic blocking agents (i.e., doxazosin, prazosin or terazosin) followed by a β-adrenergic blockade (i.e., propranolol, atenolol). This latter should never be started first because blockade of vasodilatory peripheral β-adrenergic receptors with unopposed α-adrenergic receptor stimulation can lead to a further elevation of BP. Although labetalol is traditionally considered the ideal agent due to its α- and β-adrenergic antagonism, experimental studies do not support its use in this clinical setting. As second regimen, the administration of vasodilators as calcium channel blockers (i.e., nicardipine, nifedipine) may be required to control BP. Oral and sublingual short-acting nifedipine are potentially dangerous in patients with hypertensive emergencies and are not recommend. The latest evidences into the diagnosis and treatment of hypertensive crisis due to PH and PG are reviewed here.
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Affiliation(s)
- Alberto Mazza
- Department of Internal Medicine, Santa Maria della Misericordia Hospital, Viale Tre Martiri 140, 45100, Rovigo, Italy,
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Chapter 12. Hypertension under special conditions. Hypertens Res 2014. [DOI: 10.1038/hr.2014.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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22
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Sarkar O, Baumann M. [Paroxysmal hypertension]. MMW Fortschr Med 2013; 155:44-47. [PMID: 24482935 DOI: 10.1007/s15006-013-2438-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Oliver Sarkar
- Klinikum rechts der Isar, Hochdruckambulanz, Abteilung für Nephrologie, München.
| | - Marcus Baumann
- Klinikum rechts der Isar, Forschungslabor, Hypertensiologie, München
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23
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Abstract
Post-traumatic stress disorder (PTSD) is associated with both (1) 'ill-defined' or 'medically unexplained' somatic syndromes, e.g. unexplained dizziness, tinnitus and blurry vision, and syndromes that can be classified as somatoform disorders (DSM-IV-TR); and (2) a range of medical conditions, with a preponderance of cardiovascular, respiratory, musculoskeletal, neurological, and gastrointestinal disorders, diabetes, chronic pain, sleep disorders and other immune-mediated disorders in various studies. Frequently reported medical co-morbidities with PTSD across various studies include cardiovascular disease, especially hypertension, and immune-mediated disorders. PTSD is associated with limbic instability and alterations in both the hypothalamic- pituitary-adrenal and sympatho-adrenal medullary axes, which affect neuroendocrine and immune functions, have central nervous system effects resulting in pseudo-neurological symptoms and disorders of sleep-wake regulation, and result in autonomic nervous system dysregulation. Hypervigilance, a central feature of PTSD, can lead to 'local sleep' or regional arousal states, when the patient is partially asleep and partially awake, and manifests as complex motor and/or verbal behaviours in a partially conscious state. The few studies of the effects of standard PTSD treatments (medications, CBT) on PTSD-associated somatic syndromes report a reduction in the severity of ill-defined and autonomically mediated somatic symptoms, self-reported physical health problems, and some chronic pain syndromes.
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Affiliation(s)
- Madhulika A Gupta
- Department of Psychiatry, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada.
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Mann SJ. Psychosomatic research in hypertension: the lack of impact of decades of research and new directions to consider. J Clin Hypertens (Greenwich) 2012; 14:657-64. [PMID: 23031141 DOI: 10.1111/j.1751-7176.2012.00686.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Samuel J Mann
- Division of Nephrology and Hypertension, Department of Medicine, Weill/Cornell Medical Center, New York Presbyterian Hospital, New York, NY 10021,USA.
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Handler J. Taking a family history of hypertension: is there patient care benefit? J Clin Hypertens (Greenwich) 2011; 13:133-7. [PMID: 21272202 DOI: 10.1111/j.1751-7176.2010.00404.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Abstract
J Clin Hypertens (Greenwich). 2009;11:491-497. (c)2009 Wiley Periodicals, Inc.Although the management of the labile component of blood pressure elevation is a problem often encountered by clinicians, there is a paucity of information available to guide therapeutic decisions. This review discusses the clinical relevance of blood pressure lability, the limitations of current knowledge, and possible directions for future research and clinical management.
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Affiliation(s)
- Samuel J Mann
- Division of Nephrology and Hypertension, Department of Medicine, New York Presbyterian Hospital, Weill/Cornell Medical Center, New York, NY 10021, USA.
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Seck SM, Ka EF, Niang A, Diouf B. Pseudopheochromocytoma: An uncommon cause of malignant hypertension. Indian J Nephrol 2010; 19:122-4. [PMID: 20436734 PMCID: PMC2859479 DOI: 10.4103/0971-4065.57111] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 42-year-old black African patient was admitted in the emergency department with severe headache, dizziness, and visual problems. He had been treated for hypertension diagnosed eight months ago after a similar episode. He was taking atenolol 100 mg /day, amlodipine 10 mg/day, and a combination of lisinopril 20 mg/hydrochlorothiazide 12.5 mg daily but experienced several hypertension peaks and hypotension. He adhered to treatment and was neither using traditional herbal medication nor illicit drugs. He did not smoke, but used to drink 1-2 glasses of wine after dinner. At admission, his blood pressure was 235/145 mm of Hg. His body mass index was 25.5 kg/m(2) and the waist/hip ratio was 0.9. Physical examination was unremarkable. Fundoscopic examination revealed hypertensive retinopathy. Biochemical and imaging explorations were compatible with diagnosis of pseudopheochromocytoma. Evolution was favourable after treatment with alpha-1 and beta-blokers.
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Affiliation(s)
- S M Seck
- Nephrology Department of Teaching Hospital, Aristide Le Dantec, Dakar, Senegal
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Papadopoulos DP, Mourouzis I, Votteas V, Papademetriou V. Depression masked as paroxysmal hypertension episodes. Blood Press 2009; 19:16-9. [PMID: 19929288 DOI: 10.3109/08037050903353816] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
This paper describes a clinical picture frequently seen in specialty hypertension clinics, a patient with paroxysmal or intermittent hypertension not related to pheochromocytoma. A variety of diagnostic labels given to these patients is reviewed, including pseudopheochromocytoma and panic attacks. The clinical features, pathophysiology, diagnosis and treatment of these syndromes are outlined. It is proposed that successful management of these patients may be best achieved by collaborative care between a hypertension specialist and a psychiatrist, or clinical psychologist with expertise in cognitive-behavioral panic disorder management, stress-reduction techniques including controlled breathing, and effective treatment of anxiety. The use of drugs effective for treatment of panic disorder can also be helpful in managing those patients.
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Affiliation(s)
- Dimitris P Papadopoulos
- Hypertension Clinic, Laiko University Hospital, 24 Agiou Ioannou Theologou Street,15561 Athens, Greece.
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Melo NCV, Carmo LPF, Rodrigues CE, Marques IDB, Praxedes JN. Brainstem tumour mimicking pheochromocytoma. J Hum Hypertens 2009; 23:493-4. [DOI: 10.1038/jhh.2009.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Hofer S, Steppan J, Wagner T, Funke B, Lichtenstern C, Martin E, Graf BM, Bierhaus A, Weigand MA. Central sympatholytics prolong survival in experimental sepsis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:R11. [PMID: 19196475 PMCID: PMC2688128 DOI: 10.1186/cc7709] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2008] [Revised: 01/15/2009] [Accepted: 02/06/2009] [Indexed: 12/17/2022]
Abstract
Introduction One of the main causes of death in European and US intensive care units is sepsis. It involves a network of pro-inflammatory cytokines such as TNF-α, IL-1β and IL-6. Furthermore, there is an up regulation of transcription factors such as nuclear factor (NF) κB. It has previously been shown that clonidine is able to significantly reduce pro-inflammatory cytokines in surgical patients. We therefore hypothesise that the clinically used central alpha-2 agonist clonidine has the ability to improve survival in experimental sepsis by inhibiting the sympathetic tone and consequently inhibiting the pro-inflammatory cytokine release. Methods To investigate this therapeutic potential of clonidine in a prospective randomised laboratory investigation we used a murine model of caecal ligation and puncture (CLP) induced sepsis. Animals receiving pre-emptive injections were treated with either clonidine (5 μg/kg) or dexmedetomidine (40 μg/kg) 12 and 1 hours before the operation, as well as 1, 6 and 12 hours afterwards. Another group of animals only received clonidine (5 μg/kg) 1, 6 and 12 hours after the operation, while the pre-emptive injections were normal saline. The control groups received solvent injections at the respective time points. Results Pre-emptive administration of a central sympatholytic significantly reduced mortality (clonidine: p = 0.015; dexmedetomidine: p = 0.029), although postoperative administration of clonidine failed to significantly prolong survival. Furthermore pre-emptive administration of clonidine significantly attenuated the cytokine response after CLP-induced sepsis (mIL-1beta: p = 0.017; mIL-6: p < 0.0001; mTNF-α: p < 0.0001), preserved blood pressure control (p = 0.024) and down-regulated the binding activity of NF-κB. There were no changes in the pro-inflammatory cytokine response when peripheral blood was incubated with lipopolysaccharide alone compared with incubation with clonidine (10-4 M) plus LPS (p > 0.05). Conclusions Our results demonstrate that the pre-emptive administration of either clonidine or dexmedetomidine have the ability to successfully improve survival in experimental sepsis. Furthermore, there seems to be a connection between the central muscarinic network and the vagal cholinergic response. By down-regulating pro-inflammatory mediators sympatholytics may be a useful adjunct sedative in patients with a high risk for developing sepsis.
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Affiliation(s)
- Stefan Hofer
- Department of Anaesthesiology, University Hospital Heidelberg, Heidelberg, Germany.
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