Only a few days ago, did I realize that I had missed several questions from the Dr. Pheo blog. I have not received any email alerts on new questions since late May 2018. Initially I thought perhaps it was summer time or perhaps readers found answers from previous posts. Then I saw a few comments on the blog a few days ago. That was strange because I was supposed to get email alters on new comments. I certainly did not change any settings and I checked again and found all the settings were the same.
Then I googled the problem. Wow, so many other bloggers had similar problems. It looked like Google Blogger required bloggers to re-consent receiving email alerts. The bottom line is that I can now receive email alerts of your questions. If you posted questions in late May or after, and did not receive answers from me, please post your questions again if you still need the answers.
Dr. Pheo
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Hi Dr. Pheo,
ReplyDeleteMy brother's (39yrs) free normetanephrine plasma came positive: 687 pg/ml reference range (<195 pg/ml). No other metanephrine or catecholamine test was done. He has high BP, however with medication now its under control 115/75. Resting HR is 60. He is also diagnosed with anxiety disorder but did not take any meds for it at the time the test He could not even go to the Endo due to the anxiety. He did the test on Cardio's recommendation. His Endocrinologist feels it may be due to stress/anxiety hence will do clonidine suppression test. Due to anxiety my brother could not get the suppression test done for 4 weeks.
It all started 6 weeks back when he went to ER with 180/100 bp (measured at home), this was because he didnt take any BP meds till that date despite high BP. At hospital his BP was 220/130 due to increased anxiety. We were there for 4 hours meanwhile BP came done to 180/110 in 2 hours and 160/100 in four hours. However we came back at home same day and his BP was 120/80. In our follow ups to the Cardio, his BP was 40/15mm higher at hospital, we measured. In anticipation at home bp will increase from 120/80 to 140/90. Then at clinic it will climb to 185/100. Cardiologist also checked the machine if it reads correctly. No tachycardia. Except past month he is moderately active, walking about 6K daily, running.
He was under following medication: 1 Azilsartan (40 mg), 2. Nebivolol 5 mg 3. Benidipin 8 mg at the time of test. Test was not done supine and the lab technician did not know how to handle the sample either.
Currently he also takes 0.5 mg Clonazepam for anxiety. Cardio changed Nebivolol to 200mg Labetalol twice daily, just in-case. His BP from morning to evening remains 110/70 to 120/80. He is also diagnosed with Anxiety disorder including Agoraphobia. He was extremely anxious during sample collection.
Could it be a false positive? How risky is clonidine suppression if his BP is low to begin with (say 100/60 and heart rate 65) I fear due to anticipation it rises to 140/90 to begin with.
To add further to above, in his Ultrasound of Kidney no adrenal mass was seen. There were a few cysts in urinary bladder.
Update on 28th June
Redid the test this time..normetanephrine free plasma 53.2pg/ml ref <196 pg/ml. However sample was collected at home.
Currently his BP is 100/70 and resting HR<70. Due to anxiety he gets high BP at his doctor's office. Hence Dr. is waiting for some time to reduce his BP medication.
Dear Anonymous,
DeleteIf his plasma normetanephrine fluctuates so that it can be normal, then pheo is very unlikely.
Dr. Pheo
Dear Dr Pheo
DeleteThanks for creating this useful blog.
This is Ash (nickname) from Delhi India having hypertension for last 10 years controlled with drugs my BP medicine Olmesartan 40mg od and metroprolol XR 50mg od and otherwise completely asymptomatic. During my hospital stay in April 2018 CECT Incidental findings of Exophytic soft tissue lesion with enhancing component,cystic area and calcification focus in right adrenal gland. Further investigations resulted as under:-
1. Whole body PET-CECT scan: solid cystic lesion with no abnormal FDG uptake.
2. 24 hour urine Metanephrine.01.05.2018
Metanephrine. 66.58ug Ref 74.00 -297.00
Normetanephrine 1863.20ug ref 73.00- 808.00
(I doubt I drank tea and ate banana before sample and also took my BP medicines)
3. MIBG i131 28.06.2018. Spect/CT Well defined heterogeneous density lesion (3.2x3.0x3.4cm)
No scan evidence of MIBG concentrating tumour in the body.
4. 24 hour Metanephrines 25.07.18
Metanephrine 581.79ug. Ref 74-297
Normetanephrine 143.07ug. Ref 73-808
Epinephrine. 4.72ug. Ref. 4-20
Norepinephrine. 42.92ug. Ref. 23-105
Dopamine 259.48ug Ref. 62-446
VMA 0.25ug. Ref. 1.60-7.30
My Endocrinologist suspects a Pheo. Suggests Unilateral adrenelectomy. Kindly Advice.
Ash. M63, Delhi India
Hi dr. I Had kidney stones a few months ago where the ct scan showed a 4.9 cm tumor in my adrenal medulla. My dr ordered tests and the 24 hr urine test results day for my age (38) reference range 115-695mcg /24hr
ReplyDelete(H) 1049 mcg/24 h
Comment:
A four fold elevation of urinary normetanephrines
is extremely likely to be due to a tumor, while a
four fold elevation of urinary metanephrines is
highly suggestive, but not diagnostic of the tumor.
Measurement of plasma Metanephrines and Chromogranin
A is recommended for confirmation.
THIS TEST WAS PERFORMED AT:
QUEST DIAGNOSTICS NICHOLS INSTITUTE
14225 NEWBROOK DRIVE
CHANTILLY, VA 20153-0841.
Do these levels in your opinion suggest Pheo? I have had slightly high BP and elevated heart rate for a couple
Years now but nothing super dangerously high.
Dear Sean,
DeleteWhat are the metanephrine and normetanephrine levels separately? The one you posted is for the total metanephrines (metanephrine plus normetanephrine).
Dr. Pheo
Metanephrine 221mcg
ReplyDeleteNormetanephrine 828mcg
Dear Sean,
DeleteThe results are suggestive but not strong enough to be diagnostic of pheo. The imaging characteristics of the adrenal mass are similarly important. If the radiologist thinks the tumor appears to arise from the adrenal medulla, it should be removed.
Dr. Pheo
Hi Dr. Pheo. I've enjoyed reading your posts regarding pheo, as it is something I have recently undergone testing for. In March 2018 I went to the ER for sudden onset of sinus tachycardia (150s) and my blood pressure was also high, although it came down on its own after an hour or so, and has since been controlled by atenolol. The tachy continued, and really has not subsided since. I'm taking 25mg atenolol for that and other symptoms. I since then have developed new onset headaches (feels like pressure behind my forehead/eyes), as well as fatigue,shortness of breath, chest pain, and blurred vision all of which come and go. I am a 23 yr old female with no other significant medical history.
ReplyDeleteI have had a full cardio work up (multiple ecgs, an echo), chest x-ray full bloodwork including a thyroid panel, and plasma metanephrines and urine metanephrines and catecholamines. The only abnormal result in all of this was with my metanephrines. My plasma metanephrines were elevated 1.5x the normal reference range,with normal plasma normetanephrines. The urine mets could not be completed due to some sort of analytical interference as reported by the lab. But urine catecholamines were normal, with urine epi being below reportable range.
I understand that this is within the possible false positive range. My doctor(cardiologist who ordered the metanephrines and catecholamines) wants to just refer me to an endocrinologist (3 month wait for appt!!) rather than repeating testing. I was taking atenolol at the time of testing, but had refrained from caffeine for 24 hrs before the urine and plasma collections.
I've been reading some papers about pheo, and read one that suggested that with metanephrines in the false positive range, a high ratio of metanephrine to epinephrine or of normetanephrine to norepinephrine is suggestive of pheo. Have you found this to be true?
Additionally, I have been trying to figure out what has been triggering "attacks" of these symptoms each afternoon at work, and realized that I have been eating cheese everyday at lunch. Could this be provoking an attack if it is pheo?
Another time I tend to notice bad symptoms is when I'm very hungry. Possibly on a related note, I've been doing research into POTS as my symptoms seem similar. Do you find that POTS sometimes turns out to be the correct diagnosis when someone may suspect pheo?
Thanks so much!!
Thanks so much!
Reply
Dear Amanda,
DeleteThe likelihood of pheo is not high. Panic attacks, anxiety, and POTS are common alternative diagnoses in patients once suspected of having pheo.
Dr. Pheo
Dear Dr Pheo
ReplyDeleteFirst of all please accept my apologies for wrongly placing my post and I am repeating it now and Thanks a lot for creating this useful blog.
This is Ash (nickname) from Delhi India having hypertension for last 10 years controlled with my BP medicine Olmesartan 40mg od and metroprolol XR 50mg od and otherwise completely asymptomatic.
During my hospital stay in April 2018 medical checkup and CECT Incidental findings of Exophytic soft tissue lesion with enhancing component,cystic area and calcification focus in right adrenal gland. Further investigations resulted as under:-
1. Whole body PET-CECT scan: solid cystic lesion with no abnormal FDG uptake.
2. 24 hour urine Metanephrine.01.05.2018
Metanephrine. 66.58ug Ref 74.00 -297.00
Normetanephrine 1863.20ug Ref 73.00- 808.00
(I doubt I drank tea and ate banana before sample which might have elevated normetanephrine in 24 hr urinary collection and also took my BP medicines)
3. MIBG i131 28.06.2018. Spect/CT results shows a Well defined heterogeneous density lesion (3.2x3.0x3.4cm)
No scan evidence of MIBG concentrating tumour in the body.
4. 24 hour Metanephrines 25.07.18
Metanephrine 581.79ug Ref 74-297
Normetanephrine 143.07ug Ref 73-808
Epinephrine. 4.72ug Ref. 4-20
Norepinephrine. 42.92ug. Ref 23-105
Dopamine 259.48ug Ref 62-446
VMA 0.25ug. Ref 1.60-7.30
My Endocrinologist suspects a Pheo. Suggests Unilateral adrenelectomy. Kindly Advice.
Ash. M63, Delhi India
Dear Ash,
ReplyDeleteThis is a challenging diagnosis. Can you confirm that the two urine metanephrines test results were vastly different? Both metanephrine and normetanephrine results were very different between the two tests.
It is very unusual for a pheo to be negative on both FDG pET and MIBG scan.
Dr. Pheo
Dear Dr Pheo
ReplyDeleteThanks a lot for your timely response and I do confirm that the reports of 24 hour urine Metanephrines as mentioned above are correct and they vary considerably between two reports and Metanephrines and normetanephrines are correctly mentioned as reported.
However, for the second test they kept the 24 hour urinary sample for four days in lab before conducting the test. If that could affect the results?
Another test for adrenaline, noradrenaline and urinary VMA on 17.05.2018 showed normal values as under:-
Adrenaline. 4.62 ug/day ref (<20.00)ug/day.
Noradrenaline 47.11 if/day ref (<90.00)ug/day.
Urinary VMA 4.95 mg/24hr ref 0-15mg/24 hr.
PET-CT scan dt 27.04.18 reveals:
Quote
“Solid-cystic lesion with no abnormal FDG uptake in the right adrenal gland- likely benign. However, possibility of low-grade mitotic etiology can’t be ruled out completely. Suggested FNAC Correlation C/ Close follow up.
No abnormal hypermetabolic focus noted in the visualised body to suggest mitotic etiology.”
Unquote
MIBG dated 28.06.2018.
“No scan evidence of MIBG concentrating tumour in the body”.
Testosterone, Dhea-S, Sodium and potassium in normal range.
Cortisol in normal range.
A. Aldosterone 14.0ng/Dl
DRC 79.40
Test negative for primary hyperaldosterone.
However for last four months platelets counts are low and ranging from 70,000 to 96,000 normal range (1,50,000-4,50,000) and TLC and Monocytes are slightly elevated which Doctors say are not due to suspected Pheo.
I thank you once again for your time and would be willing for further tests if suggested by you for proper diagnosis.
Ash, Male 63, Delhi, India
Dear Ash,
DeleteNow I think the probability of pheo is much lower. It is possible that the urine metanephrines results may be due to errors. If available, you can test for "plasma fractionated metanephrines".
Dr. Pheo
Dear Dr Pheo
DeleteThank you very much for your valuable response. I would check for a reliable diagnostic lab for “Plasma fractionated Metanephrines” test and would update you with the results.
Ash
Hi Ash, Check metropolis lab in Delhi. They
Deletebatch test on wednesday. The will collect on tuesday and report by thursday afternoon. It was my post you commented on initially. Regards Anonymous
Dear Dr Pheo,
DeleteFinally got my Fractionated plasma free rmetanephrines report from Metropolis today ie 06.09.2018. Which is as under:-
Metanephrines. free plasma 34 pg/ml ref <65
Normetanephrines free plasma. 57.6 pg/ml ref <196
Let me also add here I have earlier also got this Plasma free metanephrines test done on 18.07.2018 from Genetik lab (Sone how I believed this test to be wrong but now this seem to be right)and results were also normal as under:-
Metanephrines plasma 250 pg/ml. ref <390
Normetanephrine plasma. 372 pg/ml. ref <372
I may also add here that one week before these tests I have stopped consuming bananas, nuts, tea and coffee.
Through your blog I would also like to thank Anonymous here for his suggestion of Metropolis lab in Delhi. It proved to be very useful
I hope these results with earlier reports would help you in making an accurate diagnosis for Pheo in my case.
Thanking you in anticipation and regards.
Ash, Male 63, Delhi India.
Sorry for typing mistakes.
DeleteCorrection (Genetik lab) report dt 18.07.18.
Please read ref range for normetanephrine plasma as under.
Normetanephrines plasma 372 pg/ml ref <410 pg/ml.
Regards,
Ash
Dear Ash,
ReplyDeleteThe new test results, along with the old ones, effectively rule out pheo in you.
Dr. Pheo
Dear Dr Pheo,
DeleteThanks a lot for your invaluable and timely support.
Regards,
Ash, Male 63, Delhi, India
HI Dr. Pheo,
ReplyDeleteI am taking the 24 hour urine test this Sunday-Monday to rule out a pheo. My symptoms are that I presented with HBP 193/113 about three weeks ago. I have had multiple pituitary issues since 1991, prolactinoma and now suffer from growth hormone deficiency. I was prescribed BP meds at the ER, but could not get the HBP under control so I was prescribed a diuretic as well. This lowered the BP, but continue to have periodical spikes (nothing over 150/100) and what feels like panic attacks. Also, my mother had a pheo, was asymptomatic, they found it on an MRI for lower lumbar issues. My cortisol is in the normal range but on the very low end of normal and my TSH, at the ER was elevated. T3 and T4 usually present on the lower end of normal, IGF was at 85 and I failed the glucagon test. My question for you...if I do not have a pheo, any idea of what direction I should go in...I am thinking sleep apnea, but I was just wondering if any of the above information make anything jump out at you. I am a migraine sufferer, and am extremely fatigued almost all of the time. Thank you for your time!
Dear Anonymous,
DeleteI agree to check for pheo and primary hyperaldosteronism. Even if you don't have either, CPAP for sleep apnea always helps reducing blood pressure. Seeing a hypertension specialist is a good idea.
Dr. Pheo
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ReplyDeleteWe have a 27 yr old son who has been mysteriously ill his whole life. Seizures that were non convulsive, but caused learning issues and migraines until he was 17, then began to develop exercise intolerance, terribly strong underarm sweat at times ( not related to exercise), and irrational anger spells in which he mainly expressed by running or jumping around until he ran out of energy. His seizures became convulsive as well as myoclonic with injuries, which made these angry spells particularly dangerous. In 2013 his seizures became often deadly with status episodes & they were preceded with periods of nervousness and obvious stress ( foot shaking, startling at the least little noise, dilated eyes). During his 1st of 9 critical care stays in 2 yrs it was discovered he had hyperthyroidism & tachycardia, so we thought that was what was causing many issues, but over time his thyroid normalized ( he took short term anti thyroid course of drugs, became hypo, but could not tolerate any thyroid replacement hormone without going into deadly seizures.) on its own. The tachycardia stayed & eventually he was taking 630 mg of Propranolol & still had a pulse of about 90 on a good day. The stress grew worse, eyes dilated much of the time, cold hands, feet, nose, & the anger spells turned into horrific rages that put us all in danger. When he was not stressed out he was exhausted. We discovered he had reactive hypoglycemia and then a slow gut, so we have spent 3.5 yrs journaling and trying to find a way to feed him that works. He is 5'9 and weighs 124lbs. Since 2013 he began to collapse with complete paralysis for various lengths of time - usually not more than 40 minutes to an hour - after an angry meltdown. He also developed spells from 2013 onward where it started with a seizure, then he would be like a person drowning or trying to escape some monster ( altered consciousness); desperately pushing away helping hands or grabbing them. It is like fighting a little bear all over the room, with him grabbing anything and everything. Seizures punctuated these spells. His hands would be sweating & the spell would gradually calm over 40 minutes, ending with shivering and shaking all over. 3 yrs ago, in desperation ( we have seen so many dr.'s) we tried the adrenal fatigue approach & put him on an adrenal cortex supplement & licorice. He had a cortisol saliva test while on these supps because we could not take them away quickly without throwing him into a seizure crisis. His levels were at the lowest point of normal at all 4 times he was tested. It took us several yrs to get him off those things, so I will have his cortisol re-tested, but we have not found an endocrinologist yet who is very interested. So, to finish this book ( sorry!!!), we have found ways to calm his stress as much as possible - we work so hard to do it - and it is not enough. We have to use Klonopin or Valium frequently. The spells where he flops all over the place sweating etc... are much less in intensity now ( since we got rid of the adrenal supplements, which I think were too stimulating), but still there. So, finally, his blood and urine tests were similar to Amanda's ( commenter above). His blood pressure has never been a problem except for one time last year when he was paralyzed. The EMT's took it after we found it low and it was very low, but rose to normal by the time we met the paramedic. So, pheo seems unlikely, but so does pots and definitely not panic attacks. Should we be worried about another type of adrenal tumor? I am sorry to bother you, but I thought maybe you might have some idea we could investigate.
ReplyDeleteThank you kindly,
Joanie W
Dear Joanie,
DeleteI am sorry but I don't feel qualified to answer you question here.
Dr. Pheo
I am sorry if I was inappropriate to share so much info in this forum. Desperate people do desperate things, especially mothers. I was fearful he might have an adrenal tumor because of the sweating and obvious stress bouts. Since I wrote we have slowly been increasing a new epilepsy medicine that, for the first time, is helping quite a lot. He still has stress issues even though his seizures are reduced by about 70% at this point. He still has to use a lot of benzos and I wonder, after using them heavily since 2004, if that is behind the stress issues ( withdrawal). So, accept my apology please.
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