title: Severe postoperative hypoglycemia in a patient with pheochromocytoma and preclinical Cushing's syndrome.
abstract: BACKGROUND
  Postoperative hypoglycemia is not a common complication following the removal of a pheochromocytoma. Although the mechanism of hypoglycemia is not fully understood, it seems that it is caused by excessive rebound secretion of insulin after surgical resection of pheochromocytoma.
  
  
  METHODS
  We report a 43-year-old woman with a very rare association of pheochromocytoma and preclinical Cushing's syndrome (PCS) in the same adrenal gland who developed severe postoperative hypoglycemia. Pheochromocytoma was diagnosed by high serum and urine metanephrine and normetanephrine levels. PCS was characterized by blunted cortisol diurnal rhythm, low ACTH level, and failure of cortisol suppression by dexamethasone without any clinical signs of cortisol excess. In the early postoperative period after surgical removal of right adrenal gland, the patient lapsed into a stuporous state. The blood glucose level was 0.7 mmol/l. During the next 48 hours, normoglycemia was maintained with a continuous infusion of 20% glucose. On the third postoperative day, infusion was discontinued, oral feeds were introduced, and the plasma glucose level normalized. The patient did not have further episodes of hypoglycemia. Pathology revealed medullary pheochromocytoma and a cortical tumor of right adrenal gland. During the fifth postoperative day, plasma metanephrine and normetanephrine were 0.13 nmol/l and 0.30 nmol/l, respectively. Urinary metanephrine decreased to 0.5 pmol/24 h and normetanephrine to 2.8 micromol/24 h.
  
  
  CONCLUSIONS
  This report indicates the importance of close monitoring of blood glucose level in a patient with pheochromocytoma after removal of an adrenal gland.
authors.affiliation: Division of Endocrinology, Department of Internal Medicine, University Hospital Zagreb, Zagreb, Croatia. dkastelan@inet.hr
authors.forename: Darko
authors.initials: D
authors.lastname: Kastelan
authors.forename: Katja Grubelic
authors.initials: KG
authors.lastname: Ravic
authors.forename: Mirjana
authors.initials: M
authors.lastname: Cacic
authors.forename: Ranka
authors.initials: R
authors.lastname: Stern-Padovanr
authors.forename: Marijana
authors.initials: M
authors.lastname: Coric
authors.forename: Jozo
authors.initials: J
authors.lastname: Jelcic
authors.forename: Zdravko
authors.initials: Z
authors.lastname: Perkovic
authors.forename: Zlatko
authors.initials: Z
authors.lastname: Giljevic
authors.forename: Izet
authors.initials: I
authors.lastname: Aganovic
authors.forename: Mirko
authors.initials: M
authors.lastname: Korsic
mesh_terms: D000310:Adrenal Gland Neoplasms / Q000150:complications*; D000328:Adult; D003480:Cushing Syndrome / Q000150:complications*; D005260:Female; D006801:Humans; D007003:Hypoglycemia / Q000150:complications*; D008279:Magnetic Resonance Imaging; D010673:Pheochromocytoma / Q000150:complications* / Q000000981:diagnostic imaging / Q000473:pathology; D011183:Postoperative Complications; D011859:Radiography