pheochromocytoma is a rare tumor arising from chromaffin cells of the sympathetic nervous system which releases catecholamines . this report presents the case of a patient with pheochromocytoma who had a past medical history of hypertension and diabetes mellitus . we successfully performed surgical resection of a pheochromocytoma associated with a systemic inflammatory syndrome indicated by abnormal liver function tests and severe leukocytosis , and with stress - induced cardiomyopathy presumably due to catecholamine overproduction . moreover , we successfully treated the patient 's uncontrolled diabetes mellitus , and other associated clinical manifestations found at the time of presentation . a 49-year - old male presented to our hospital complaining of chest pain . for the past few years in addition to the chest pain , the patient developed pyrexia and perspiration beginning a week before admission . he initially visited another hospital for worsening symptoms where examination found abnormal electrocardiography results ( the st elevation in leads avl and v1 to v6 ) , leukocytosis , and abnormal liver function tests . abdominal computed tomography ( ct ) results showed hepatic parenchymal abnormality and a tumor on the left adrenal gland . seven years prior to presentation the patient had been diagnosed with hypertension and was put on antihypertensive medication , but remained poorly controlled over the 3 years prior to presentation . he was also diagnosed with diabetes mellitus 8 years ago and has been treated with hypoglycemic agents , but his blood sugar was poorly controlled . his blood pressure was 140/90 mm hg with a pulse rate of 66 beats per minute , was breathing at a rate of 20 times per minute , and had a body temperature of 36.8. he had clear consciousness without signs of conjunctival pallor , scleral jaundice , dehydration , and absent dilatation of the jugular vein . on chest auscultation breath sounds were clear without wheezing or crackles detected . cardiac auscultation revealed a heartbeat that was regular without murmur . on examining the abdomen , bowel sounds seemed reduced and the right upper abdomen had slight but not significant tenderness . blood tests resulted as follows : aspartate aminotransferase ( ast ) 444 iu / l , alanine aminotransferase ( alt ) 469 iu / l , white blood cell count 50,000/l , hepatitis b surface antigen ( hbsag ) negative , anti - hbsab positive , antihepatitis c virus ( anti - hcv ) antibody ( ab ) negative , antihepatitis a virus ( anti - hav ) immunoglobulin m ( igm ) ab negative , and anti - hav igg ab positive . on the day of admission to our hospital , the blood test results were as follows : hemoglobin 15.8 g / dl , white blood cell count 59,360/l , platelet count 244,000/l , erythrocyte sedimentation rate 4 mm / hr , and c - reactive protein 3.446 mg / l , blood urea nitrogen 22.7 mg / dl , serum creatinine 0.76 mg / dl , serum calcium 7.2 mg / dl , inorganic phosphorous 2.0 mg / dl , sodium 134 mmol / l , and potassium 4.4 mmol / l . the results also showed that total protein was 5.5 g / dl , albumin was 2.7 g / dl , ast 156 iu / l and alt 317 iu / l , alp 289 iu / l , and total bilirubin 1.05 mg / dl . c - peptide was 0.40 ng / ml ( range , 0.48 to 3.3 ) , and 2 hours after a meal it was 0.66 ng / ml . lactate dehydrogenase was 1,240 iu / l . creatine kinase mb and troponin - t were found to be 5.99 ng / ml ( range , 0.6 to 6.3 ) and 0.073 ng / ml ( range , 0.0 to 0.1 ) , respectively . abdominal ct at another hospital detected several small - sized and low attenuation lesions on both lobes of the liver , and a 55-cm - sized tumor enhanced unevenly on the left adrenal gland ( fig . 1 ) . electrocardiography revealed sinus rhythm with t wave inversion and qt interval prolongation observed in leads ii and v1 to v6 ( fig . although the cardiac ejection fraction was 69% , echocardiography detected severely hypokinetic wall motion of mid - left ventricle sparing basal and apical wall motions . the results of 24 hours urinalysis were as follows : vanillylmandelic acid ( vma ) 33.93 mg / day ( range , 0 to 8.0 ) , metanephrines 20.45 mg / day ( range , 0 to 1.3 ) , epinephrine 2,034 g / day ( range , 0 to 40 ) , norepinephrine 978 g / day ( range , 0 to 80 ) , serum epinephrine 1,221 pg / ml ( range , 0 to 120 ) , and serum norepinephrine 778 pg / ml ( range , 100 to 410 ) . other tests including aldosterone , plasma renin activity , and cortisol were all normal . on i - metaiodobenzylguanidine scan examination , uptake of the radioactive isotope was increased in the left adrenal gland , but no other lesions were found ( fig . the patient was diagnosed with a pheochromocytoma on the left adrenal gland . on the 12th day of admission oral phenoxybenzamine administration after 19 days of administration , resection of the left adrenal gland was performed under laparoscope . the size of the resected tumor was 55 cm , and the surface was a mixture of a hemorrhagic and a cystic lesion . the tissue pathological examination showed the tumor cells with eosinophillic cytoplasm and polygonal shape surrounded by mesenchyma of vasculature on h&e staining , while immunohistochemical stains of chromogranin , synaptophysin , and s-100 immunoperoxidase staining revealed the proper findings to diagnose pheochromocytoma as positive ( fig . 4 ) . thirteen days after tumor resection a panel of endocrine tests was performed to follow - up on the pheochromocytoma . a 24 hours urinalysis showed a vma of 6.51 mg / day with metanephrines at 0.61 mg / day , epinephrine at < 5 g / day , norepinephrine at 101.48 g / day , serum epinephrine at < 15 pg / ml , and serum norepinephrine at 536.60 pg / ml ( table 1 ) . when first admitted , the patient had uncontrolled blood pressure even with amlodipine 10 mg and irbesartan 150 mg plus 12.5 mg of hydrochlorothiazide . however , when discharged , the patient had controlled blood pressure with a reduced dosage of antihypertensives consisting of amlodipine 10 mg and irbesartan 150 mg . prior to his admission to the outside hospital , the patient had no history of new drug administration that might cause liver function failure . he also had no history of drinking and had a normal body weight ( body mass index 23 kg / m ) . a panel for hepatic viral disease ( hepatitis b virus , hcv , hav ) was negative , and no abnormality was found through immunological testing ( antismooth muscle , antinuclear , antimitochondria antibody ) , or screening for genetic diseases ( plasma iron parameters , ceruloplasmin , cu ) . this led to the challenge of finding a clear cause for the liver function failure . the liver function improved with conservative treatment , and had resolved by the time phenoxybenzamine was administered ( table 2 ) . on the 22nd day after iu / l , respectively ( table 2 ) , and normal liver function test remained within normal limits at 80 days after surgery . after admission to our hospital , the patient 's leukocytosis continued , and follow - up tests were performed to examine for secondary causes such as blood diseases , infection , and pheochromocytoma . on the fourth day of phenoxybenzamine administration the white blood cell count had recovered to 5,900/l and continued to be within the normal range even after surgery ( table 2 ) . echocardiography indicated cardiac ejection fraction of 78% on the 15th day after admission ( fourth day of phenoxybenzamine administration ) , and no left ventricle wall motion abnormalities were observed . on admission the patient was administered insulin and metformin , but the range of blood glucose fluctuation was wide . however , after surgery blood glucose levels returned to the normal range without the previously administered medications . previously suppressed c - peptide secretion was recovered 3 days after surgery . on the 80th day after surgery pheochromocytoma can present with various symptoms , and it can be life threatening if diagnosis and treatment are delayed . the patient was suspected to have hyperacute liver failure or systemic inflammatory syndrome on his initial admission , but during the diagnostic process a tumor was found in the left adrenal gland which led to a diagnosis of pheochromocytoma . however , there were confusing features for the case study as follows . in this case norepinephrine overproduction stimulates  adrenalin receptors in the blood vessels which leads to increased resistance of liver arterioles and veins , and decreased blood flow and oxygen volume to the liver . repeated overproduction can cause damage to hepatocytes which leads to liver function failure . in this case , severely impaired liver function was observed , but looking for the cause did not reveal any abnormal findings . in addition , although the patient 's liver function abnormality improved with conservative treatment on admission , and the results returned to the normal range completely after pheochromocytoma surgery ( table 2 ) . therefore , in this case it is suggested that abnormal liver function could be a secondary change induced by the pheochromocytoma . the previous cases reports mainly showed liver function test results increasing 2- or 3-fold which is not severe . a case moran et al .   reported describes a patient with an ast of 270 iu / l and an alt of 202 iu / l , but the patient was admitted for chest pain and pyrexia as the chief complaints , diagnosed with myocardial infarction , and only later found to have a pheochromocytoma . this differs from our case since myocardial infarction can be a cause of abnormal liver function . in the past , several case reports have described slight and moderate leukocytosis , but only a case from french and campagna   in 1961 and this case report a marked increase of the white cell blood count . french and campagna   confirmed that their patient with perspiration and mandibular pain as chief complaints showed pyrexia ( 36.6 to 39.3 ) , and white blood cell count increased to 41,500/mm . since there were no abnormalities on examinations causing pyrexia and leukocytosis , it was considered as the secondary changes from pheochromocytoma . without special treatment the white blood cell count decreased and normalized after surgery . in our case , there were no wide ranges of tumor necrosis that could have caused a marked increase in the white blood cell count . the patient had taken antibiotics for 2 days for pyrexia and pyuria in another hospital he visited , but no signs of pyrexia and pyuria were found in our hospital . moreover , abdominal ct found multiple lesions on the liver which were confirmed on magnetic resonance imaging , but he was suspected of having a cystic neoplasm or hamartoma since there was insufficient evidence to confirm the condition as infection . in our hospital , urine , sputum , and blood culture tests were performed , all of which were negative . if catecholamines are overproduced , lymphocyte and white blood cell count increases through 2-adrenalin receptors . meanwhile , there are several articles that suggest the leukocytosis could represent a systemic inflammatory response induced by interleukin-6 which is secreted from the pheochromocytoma . kang et al .   published an article in 2005 , suggesting that increases in interleukin-6 were accompanied by increased c - reactive protein and fibrinogen , with abnormalities in white blood cell count and liver function tests . it is rare to find a pheochromocytoma patient with stress - induced cardiomyopathy , but recent studies have reported these cases . stress - induced cardiomyopathy is an acute left ventricular dysfunction accompanied by left ventricular regional wall motion abnormality resulting from a sudden emotionally or physically stressful event . serum epinephrine concentration is raised and functions with the 2-adrenalin receptor to decrease myocardial contractility with a change of signaling from gs protein to gi protein in the ventricular cardiac muscle cells . in most cases , left ventricle dysfunction is reversible and has positive consequences . in this case study , on the day of admission echocardiography showed the patient 's cardiac ejection fraction was decreased and left ventricular regional wall motion abnormality was observed . the patient 's electrocardiography found st segment elevation at the outside hospital 3 days prior to the admission ; however , the pattern was not typical of acute coronary syndrome . troponin - t is a well - known marker which usually persists elevated level for 7 days after myocardiac infarction . however , it was within the normal range when the patient was admitted to our hospital . for these reasons a japanese case study reported that 38% of pheochromocytoma patients have diabetes and 51% have impaired glucose tolerance . when epinephrine is secreted , production of glucose is increased and consumption is decreased in the liver under a  adrenalin mediated mechanism . there are several cases suggesting that after pheochromocytoma has been treated by surgical resection , symptoms of diabetes and impaired glucose tolerance improve . however , there are rare cases reporting a full recovery of diabetes . the domestic cases reporting full recovery of diabetes mellitus with treatment of pheochromocytoma only includes a case reported by hong et al .   in 2001 and a case by cho et al .   in 2007 . reported that a diabetic patient medicated with oral hypoglycemic agents for 2 years ( hemoglobin a1c , 7.5% ) was completely cured after pheochromocytoma treatment . cho et al .   reported on a diabetic patient diagnosed 6 months previously for hyperglycemia ( hemoglobin a1c , 15% ) and then coincidently diagnosed with pheochromocytoma . the patient in this case had diabetes mellitus for 8 years , and insulin and oral hypoglycemic agents were administered due to elevated blood glucose just before admission . however , it is significant that diabetes in this patient showed complete remission after pheochromocytoma surgery . the patient had a hemoglobin a1c of 10.7% before surgery , but after surgery and without the use of oral hypoglycemic agents and insulin , his blood glucose , hemoglobin a1c , and c - peptide normalized . in this case , a follow - up test on the 13th day after surgery showed a decreased , but still slightly higher than normal level of norepinephrine in the serum and secreted in the urine . however , according to previous reports , the diagnostic specificity of norepinephrine for pheochromocytoma varies between 81% to 100% . additionally , a study of receiver operating characteristic curve analysis on diagnosis showed that the 24 hours urinalysis of total metanephrines is more useful for diagnosing pheochromocytoma than the 24 hours urine catecholamines , and some studies reported that serum catecholamines are less useful than other examinations such as 24 hours urinalysis of vma , catecholamines , or free metanephrines . in this case report the fact that total urinary metanephrines , a more sensitive test for diagnosing pheochromocytoma , became normal suggests that no remaining tumor exists . however , follow - up studies are necessary to monitor the possible recurrence of pheochromocytoma . thus , pheochromocytoma can be cured completely with accurate medicinal and surgical treatment after diagnosis , and its related clinical conditions tend to be reversible . when treating patients with typical symptoms of pheochromocytoma accompanied by various clinical symptoms related to catecholamine overproduction , it is important to include pheochromocytoma on the differential diagnosis and diagnose at an early stage . pheochromocytoma can present with various clinical symptoms and can be life - threatening if not treated . however , early diagnosis and accurate treatment can bring a high rate of complete cure . the authors report a case of a patient with pheochromocytoma accompanied by rare clinical symptoms such as a systemic inflammatory syndrome with abnormal liver function tests and severe leukocytosis , and stress - induced cardiomyopathy induced by catecholamine overproduction . the patient also had a history of hypertension and diabetes mellitus that resolved with surgical resection of the pheochromocytoma .
pheochromocytoma is a rare neuroendocrine tumor arising from the medulla of the adrenal glands , which causes an overproduction of catecholamines . the common symptoms are headache , palpitations , and sweating ; however , various other clinical manifestations might also be present 
 . accurate diagnosis of pheochromocytoma is important because surgical treatment is usually successful , and associated clinical problems are reversible if treated early . 
 a 49-year - old man with a history of uncontrolled hypertension and diabetes mellitus presented with chest pain , fever , and sweating . 
 his liver function tests and white blood cell counts were markedly increased and his echocardiography results suggested stress - induced cardiomyopathy . 
 his abdominal computed tomography showed a 55-cm - sized tumor in the left adrenal gland , and laboratory tests confirmed catecholamine overproduction . 
 after surgical resection of the left adrenal gland , his liver function tests and white blood cell counts normalized , and echocardiography showed normal cardiac function . 
 moreover , his previous antihypertensive regimen was deescalated , and his previously uncontrolled blood glucose levels normalized without medication .