van der Heide et al. Journal of Medical Case Reports 2011, 5:368 http://www.jmedicalcasereports.com/content/5/1/368 C A S E R E P O R T JOURNAL OF MEDICAL CASE REPORTS Open Access Torsades de pointes during laparoscopic adrenalectomy of a pheochromocytoma: a case report Kinge van der Heide1, Ann de Haes2, Götz JK Wietasch3, Ans CP Wiesfeld4 and Herman GD Hendriks3* Abstract Introduction: Torsades de pointes is a rare but potentially lethal arrhythmia. The amount of literature available on Torsades de pointes occurring in patients with pheochromocytoma is limited, and we found no literature describing this dysrhythmia in a patient with pheochromocytoma under anesthesia. Case presentation: We describe the case of a 42-year-old Caucasian woman without QT prolongation preoperatively with recurrent Torsades de pointes during laparoscopic removal of a pheochromocytoma. Torsades de pointes mainly occurs in the setting of a prolonged QT interval. This patient neither had a prolonged QT preoperatively nor was her family history suspect for a congenital long QT syndrome. Most likely, our patient had an acquired long QT syndrome, elicited by the combination of flecainide, hypomagnesemia and adrenergic stimulation during manipulation of the tumor. Conclusion: We show that in the case of a surgical pheochromocytoma removal, perioperative conditions can elicit an acquired or previously unknown congenital long QT syndrome. Therefore, preoperative a- and b-blockade is advised, QT-prolonging drugs should be avoided and potassium and magnesium plasma levels should be kept at normal to high levels. Introduction Pheochromocytomas are catecholamine-producing neu- roendocrine tumors arising from the chromaffin cells of the adrenal medulla or extraadrenal paraganglia. A pheochromocytoma is a potential life-threatening dis- ease with a high risk of cardiovascular complications such as myocardial infarction, arrhythmias, catechola- mine-induced cardiomyopathy, stroke and pulmonary edema. It is a rare neoplasm, occurring in one to two per 1000 patients with hypertension. The relatively high prevalence of pheochromocytoma in autopsy studies (0.05%) indicates that the diagnosis is often missed [1]; the overall incidence is estimated to be 1.6 to 8 cases per million inhabitants per year [1]. Traditionally, adrenalectomy for pheochromocytoma has been performed by open lateral retroperitoneal sur- gery [2]. Nowadays, laparoscopic removal of intraadrenal * Correspondence: H.G.D.Hendriks@umcg.nl 3Department of Anaesthesiology, University Medical Centre Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands Full list of author information is available at the end of the article and extraadrenal pheochromocytomas is the preferred surgical treatment because it reduces postoperative mor- bidity, hospital stay and costs compared with conven- tional laparotomy [1]. Induction of general anesthesia and surgical tumor manipulation are the most well- known stimuli to evoke an acute catecholaminergic cri- sis. About 25% to 50% of hospital deaths of patients with pheochromocytoma occur during surgery [3]. This report describes torsades de pointes (TdP) in a patient during laparoscopic removal of a pheochromocytoma as a rare perioperative complication. Case presentation A 42-year-old Caucasian woman was referred to our university hospital because of a pheochromocytoma of the left adrenal gland. For one year, she had experienced episodic headaches, palpitations, sweating, chest discom- fort, orthostatic hypotension and fatigue. A computed tomography scan showed a large adrenal mass, and urine and blood tests confirmed the diagnosis of a cate- cholamine-producing mass (mainly epinephrine and © 2011 van der Heide et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.