Occasionally a patient with Munchausen syndrome may inject epinephrine to produce symptoms suggestive of pheochromocytoma. Serum chromogranin A is released along with catecholamines and should be elevated in true pheochromocytoma. Other inconsistencies may be detected, but the patient will often deny and resist the diagnosis.


Clinical findings associated with excess epinephrine:

(1) headache

(2) tremor

(3) tachycardia

(4) hypertension


Findings that may suggest factitious disease:

(1) history of anxiety, depression or drug abuse

(2) close contact with health care (self, friend or relative)

(3) evidence of self-injection

(4) history of factitious disease

(5) history of multiple previous physicians, hospitalizations and/or surgery


Laboratory findings:

(1) elevated serum levels of epinephrine

(2) serum levels of epinephrine vary markedly between different samples

(3) normal serum norepinephrine levels

(4) normal clonidine suppression test

(5) normal serum chromogranin A levels

(6) increased urinary epinephrine levels

(7) low to normal urinary norepinephrine and catecholamine metabolite levels


Imaging studies:

(1) The adrenal glands show a normal size on CT or MRI scans.

(2) A scan with 131-metaiodobenzylguanidine (131-MIBG) is normal.


Differential diagnosis:

(1) A pheochromocytoma that only secretes epinephrine.

(2) Extra-adrenal pheochromocytoma (10% of pheochromocytomas).


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