A case of pheochromocytoma and the clinical biases which contributed to misdiagnosis
CCCF ePoster library. Sprigg L. Oct 4, 2017; 198109; 107
Lyndsay Sprigg
Lyndsay Sprigg
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A case of pheochromocytoma and the clinical biases which contributed to misdiagnosis

Sprigg, Lyndsay 1; Tan, Edmund 2; Haroon, Babar 2

1 Department of Internal Medicine, Dalhousie Univeristy, Halifax, Canada; 2 Department of Critical Care, Dalhousie University, Halifax, Canada

Introduction: Pheochromocytoma is a rare neuroendocrine tumour classically associated with adrenergic symptoms including palpitations, hypertension, paroxysmal headaches and diaphoresis, though clinical presentation is variable.  Incidence is estimated at 0.8 per 100,000 people, however this is likely an underestimation as half of these tumours are identified at autopsy. We present a case of a previously well, 59-year-old female misdiagnosed with acute coronary syndrome during a hospital stay that ended with a fatal intracranial hemorrhage. A pheochromocytoma was found at the time of organ donation, which in retrospect, explained the patient’s presentation.

Objectives: The analysis of this case will highlight the subtleties of pheochromocytoma presentation as well as sources of clinical bias which contributed to premature diagnostic closure and misdiagnosis.

Methods:  Literature reviews of both atypical presentations of pheochromocytomas and clinical biases were performed using PubMed and studies were included based on their relevance to the clinical case. 

Results: A multitude of case reports exist, depicting the unusual and varied presentation of a pheochromocytoma. Many of these case reports include presentations of pheochromocytomas with features of acute coronary syndrome or cardiac decompensation, however, none of these explicitly identified the cognitive bias that contributed to the missed diagnosis. Our case highlights multiple sources of diagnostic error including availability bias, framing effect, and diagnostic anchoring. 

Conclusion: While presentations of pheochromocytoma are rare, they can also be subtle and cognitive biases can result in anchoring on a more common, but incorrect, diagnosis. It is important to have a high index of suspicion for pheochromocytoma as when it does exist, it is commonly missed. Furthermore, it is important to be aware of and guard against the various types of cognitive bias that impact patient outcomes. 

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