Pediatric patients could possibly be misdiagnosed with ADHD when in fact they have rare tumors, as many of the symptoms of pheochromocytomas and paragangliomas (PHEO/PGL) overlap with symptoms of ADHD. The consequence of such a misdiagnosis can be dangerous as treatments for ADHD may exacerbate the symptoms of PHEO/PGL and potentially lead to hypertensive crisis.

Researchers carried out a retrospective study of PHEO/PGL patients at the National Institutes of Health (NIK) Clinical Center between 2006 and 2014. They found during this period 43 patients were diagnosed with PHEO/PGL and 9 (21%) had a diagnosis of ADHD, this is compared to just 7.2% in the general population (p=0.0328).  

The mean age of ADHD diagnosis for the patients was 8±3 years, while the first symptom attributed to PHEO occurred at the mean age of 11±3 years, with the mean age of tumor identification a year later at 12±3 years. Post-resection surgery follow-ups (that occurred between 1.3 and 3.2 years after), showed that 3 of the 9 patients had a resolution of the symptoms initially attributed to ADHD.

The follow-up also found that 6 of the 9 ADHD patients no longer had signs of PHEO/PGL, with 1 patient still being monitored and 2 showing metastatic disease. Of the 6 patients with persistence of ADHD symptoms, 2 have metastatic PGL with persistent elevation of tumor metabolites, and 2 are continuing with stimulant medication. 

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In light of these findings, the authors reiterated the DSM-5 and AAP stances on ADHD diagnosis; as a diagnosis of exclusion using observations from multiple parties to verify that the symptomology matches the diagnosis. Amphetamines prescribed to ADHD patients with PHEO/PGL tumors can launch a process of blocking re-uptake of norepinephrine and dopamine, blocking catecholamine degradation. Stimulants used on top of already elevated norepinephrine and dopamine in PHEO/PGL patients can potentiate sympathomimetic effects.

Four of the patients in the study exhibited hypertension and with the level of ADHD medication prescriptions rising, the authors of the study point out how, “hypertension is rare in the pediatric population, so practitioners should perform a thorough workup of organic causes.”

They continue, “It is imperative that a thorough evaluation for PHEO/PGL is performed in a child with ADHD-symptoms and hypertension, especially if there is a family history of neuroendocrine disorders.” They appeal for further studies that incorporate prospective screening for ADHD children with PHEO/PGL as compared with children with other types of tumors.

“These observations point to a need for pediatric patients with ADHD and hypertension to undergo a thorough evaluation to rule out the presence of a PHEO/PGL prior to initiation on stimulant medication,” concluded the authors. The full findings of the study are published in Hormone and Metabolic Research. 

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