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CATECHOLAMINES(Adrenaline and Nor-Adrenaline)

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Plasma measurement of adrenaline & noradrenaline.

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Catecholamines (Adrenaline and Nor-Adrenaline) - Comprehensive Medical Test Guide

  • Section 1: Why is it done?
    • Test Overview: This test measures the levels of catecholamines (epinephrine/adrenaline and norepinephrine/nor-adrenaline) in blood or urine. These are stress hormones produced by the adrenal glands and sympathetic nervous system that regulate heart rate, blood pressure, metabolism, and stress response.
    • Primary Indications: Suspected pheochromocytoma or paraganglioma (catecholamine-secreting tumors)
    • Investigation of severe or resistant hypertension (high blood pressure)
    • Evaluation of symptoms: excessive sweating, palpitations, tremor, anxiety, headaches, and chest or abdominal pain
    • Assessment of autonomic nervous system dysfunction
    • Monitoring of certain neuroendocrine tumors and their treatment response
    • Investigation of episodic symptoms suggestive of catecholamine excess
    • Typical Timing: Testing is performed when patients present with suggestive symptoms, as part of hypertension workup, or for screening in families with hereditary conditions predisposing to catecholamine-secreting tumors (MEN2, NF1, SDH mutations).
  • Section 2: Normal Range
    • Plasma Catecholamines (seated, supine position):
    • Epinephrine: <50 pg/mL (<0.28 nmol/L)
    • Norepinephrine: <70-100 pg/mL (<0.41-0.59 nmol/L)
    • 24-Hour Urine Metanephrines (preferred screening test):
    • Metanephrine: <75-100 µg/24 hours
    • Normetanephrine: <100-190 µg/24 hours
    • Plasma Free Metanephrines (alternative screening):
    • Metanephrine: <30 pg/mL
    • Normetanephrine: <100 pg/mL
    • Units of Measurement: pg/mL (picograms per milliliter), nmol/L (nanomoles per liter), µg/24 hours (micrograms per 24 hours)
    • Interpretation:
    • Normal: Values within reference range indicate appropriate catecholamine regulation and make pheochromocytoma unlikely
    • Elevated: Values >4 times the upper normal limit are highly suggestive of catecholamine-secreting tumors
    • Borderline Elevated: Values 1-4 times the upper normal limit warrant repeat testing or additional investigation
  • Section 3: Interpretation
    • Markedly Elevated Results (>4x upper normal limit):
    • Highly suggestive of pheochromocytoma or paraganglioma; imaging studies (CT, MRI, PET scan) should be pursued
    • Disproportionate elevation of epinephrine suggests adrenal medulla involvement
    • Predominant norepinephrine elevation may suggest extra-adrenal paraganglioma
    • Mildly to Moderately Elevated Results (1-4x upper normal limit):
    • May indicate early or episodic catecholamine release from tumor
    • Could reflect stress, anxiety, pain, or medications affecting results
    • Repeat testing under controlled conditions recommended
    • Normal Results:
    • Pheochromocytoma or paraganglioma is effectively ruled out with high sensitivity (>95%) for plasma metanephrines
    • Symptoms may be attributed to other causes such as anxiety disorders, thyroid dysfunction, or cardiac arrhythmias
    • Factors Affecting Results:
    • Medications: Decongestants, sympathomimetic drugs, tricyclic antidepressants, stimulants, pseudoephedrine
    • Position during blood draw: Supine position for 30 minutes preferred to minimize stress-induced elevation
    • Physical or emotional stress, pain, caffeine intake, nicotine use
    • Recent exercise or strenuous activity
    • Sample handling: Requires immediate cooling and rapid transport to laboratory
    • Clinical Significance Patterns:
    • Elevated epinephrine >450 pg/mL suggests adrenal medullary tumor
    • Plasma metanephrines more sensitive and specific than plasma catecholamines for screening
    • 24-hour urine metanephrines show cumulative hormone excretion and are less affected by episodic release
  • Section 4: Associated Organs
    • Primary Organ Systems Involved:
    • Adrenal Glands: Bilateral structures atop kidneys producing catecholamines from the medulla
    • Sympathetic Nervous System: Produces catecholamines throughout the body via sympathetic neurons
    • Central Nervous System: Regulates catecholamine production and release in response to stress
    • Diseases Associated with Abnormal Results:
    • Pheochromocytoma: Catecholamine-secreting tumor of adrenal medulla (90% of cases)
    • Paraganglioma: Extra-adrenal catecholamine-secreting tumors arising from chromaffin tissue
    • Multiple Endocrine Neoplasia Type 2 (MEN2): Genetic syndrome predisposing to pheochromocytoma
    • Neurofibromatosis Type 1 (NF1): Associated with increased risk of pheochromocytoma
    • Von Hippel-Lindau Disease: Hereditary cancer syndrome with pheochromocytoma risk
    • Familial Paraganglioma Syndrome: SDH gene mutations causing paraganglioma predisposition
    • Resistant Hypertension: Severe blood pressure elevation resistant to standard therapy
    • Anxiety Disorders: May show mildly elevated catecholamines due to psychological stress
    • Potential Complications from Abnormal Catecholamine Levels:
    • Hypertensive Crisis: Sudden, severe blood pressure elevation (may exceed 200/150 mmHg)
    • Myocardial Infarction: Excessive catecholamines cause increased myocardial oxygen demand and coronary vasoconstriction
    • Cerebrovascular Accident (Stroke): Severe hypertension from catecholamine excess can cause bleeding or infarction
    • Cardiomyopathy: Chronic catecholamine excess can lead to dilated cardiomyopathy (takotsubo or stress cardiomyopathy)
    • Arrhythmias: Catecholamines increase cardiac irritability and may cause atrial or ventricular arrhythmias
    • Acute Kidney Injury: Severe hypertension from catecholamine excess damages renal vasculature
    • Metabolic Derangement: Hyperglycemia from increased glycogenolysis and lipolysis
  • Section 5: Follow-up Tests
    • Recommended if Catecholamines Elevated:
    • Imaging Studies: CT scan (preferred first-line), MRI, or PET-CT to locate the tumor
    • Functional Imaging: Iodine-123 MIBG scintigraphy or positron emission tomography (PET/CT with 68Ga-DOTATATE or 18F-FDOPA)
    • Plasma Chromogranin A: Confirmatory marker for neuroendocrine tumors; elevated in >90% of pheochromocytoma cases
    • 24-Hour Urine Catecholamines: Confirm plasma findings with alternative specimen collection
    • Blood Pressure Monitoring: Continuous or ambulatory blood pressure monitoring to assess hypertension severity and response to treatment
    • Cardiac Evaluation: ECG, echocardiogram, or cardiac troponins to assess myocardial stress and function
    • Genetic Testing: Consider for patients with paraganglioma, multiple tumors, or family history; screen for SDH, RET, NF1, VHL mutations
    • Additional Tests Based on Clinical Context:
    • Thyroid Function Tests (TSH, Free T4): If MEN2 suspected; pheochromocytoma associated with medullary thyroid cancer
    • Serum Calcium: Screen for hyperparathyroidism in MEN2 syndrome
    • Plasma Renin and Aldosterone: If renal artery stenosis suspected as alternative cause of hypertension
    • Thyroid and Parathyroid Ultrasound: If syndromic pheochromocytoma suspected
    • If Results Normal but Suspicion Remains High:
    • Repeat Testing: Optimal when symptoms occur; collect sample during or immediately after symptom episode
    • Clonidine Suppression Test: Can be used if initial catecholamine levels borderline; catecholamines suppress after clonidine in essential hypertension but not pheochromocytoma
    • Psychiatry Referral: Consider if anxiety disorder or panic attacks suspected as cause of symptoms
    • Monitoring Schedule for Known Pheochromocytoma:
    • Post-Surgical: Catecholamine levels at 1 month and 3 months after tumor removal
    • Annual Screening: For hereditary syndromes or family history; includes plasma metanephrines or 24-hour urine metanephrines
    • Periodic Imaging: Follow-up imaging at 6-12 months if tumor not surgically removed
    • Biochemical Testing: Every 1-2 years for patients treated with chemotherapy or targeted therapy
  • Section 6: Fasting Required?
    • Fasting Requirement: NO - Fasting is NOT required for catecholamine testing
    • Blood Pressure and Heart Rate Baseline:
    • Patient should rest in supine position for 20-30 minutes prior to blood draw to minimize stress-related catecholamine elevation
    • Baseline blood pressure and heart rate should be recorded at time of collection for interpretation purposes
    • Medications to Avoid:
    • Decongestants and nasal sprays containing phenylephrine or pseudoephedrine (discontinue 48 hours before test)
    • Stimulant medications (amphetamines, methylphenidate; hold if possible)
    • Tricyclic antidepressants (amitriptyline, nortriptyline; discontinue 48-72 hours if feasible)
    • Sympathomimetic drugs (ephedrine, phenylpropanolamine)
    • Some antipsychotic medications may be withheld if clinical situation allows
    • SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs) generally do NOT need to be discontinued
    • Always consult with ordering physician before discontinuing any medications
    • Dietary Restrictions:
    • Avoid for 24 hours before test: Caffeine-containing beverages (coffee, tea, cola, energy drinks)
    • Avoid for 24 hours before test: Foods rich in tyramine (aged cheeses, cured meats, fermented foods, soy sauce, soy products, yeast extracts)
    • Avoid for 24 hours before test: Chocolate or cocoa products (contain phenethylamine)
    • Avoid for 24 hours before test: Citrus fruits and citrus juices (may affect test results)
    • Avoid for 24 hours before test: Nicotine and tobacco products (including smoking and nicotine patches)
    • Avoid for 24 hours before test: Alcohol consumption
    • Activity Restrictions:
    • Avoid strenuous exercise or vigorous activity for at least 12-24 hours before testing
    • Minimize physical and emotional stress on the day of test collection
    • Avoid cold exposure immediately before blood draw (can stimulate catecholamine release)
    • Sample Collection Specifications:
    • Blood Sample: Collected in chilled EDTA tubes (lavender top) with glycerol or boric acid as preservative
    • Timing: Draw in morning preferred; if episodic symptoms occur, collection during symptom episode optimal
    • Temperature Control: Sample must be kept on ice and immediately transported to laboratory; catecholamines are heat-labile
    • Transport: Deliver to laboratory within 15-30 minutes to prevent oxidation and degradation
    • 24-Hour Urine: Collected in acid-containing container (provided by laboratory); record collection times accurately
    • Additional Patient Preparation Instructions:
    • Schedule test appointment early in morning to minimize daily stress factors
    • Arrive 15-20 minutes early to allow adjustment period and stress reduction before collection
    • Notify laboratory of current medications, recent illness, or acute stress if present
    • Continue regular medications unless specifically instructed otherwise by physician

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