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A pre-operative random cortisol Casein kinase 2 level was within the normal range (206?nmol/l at 0730?h), however Friedeman et al. argue that a single determination of eucortisolism is insufficient to exclude Cushing's syndrome. In mild, or subclinical Cushing's syndrome hypercortisolism may be intermittent or short-term, necessitating two or more measures of cortisol, and at two different time periods (8). In retrospect, at follow-up, the child's body composition was leaner and his facial features were thinner, raising the likelihood of previously unrecognized Cushing's syndrome. As regards the second criterion, a pre-operative ACTH level was not assessed, however the clinical finding of gum hyperpigmentation at the post-operative follow-up may be a residual indicator of previously elevated ACTH Trichostatin A nmr levels. Criterion three was clearly fulfilled as outlined in the case report with grossly elevated plasma and urine catecholamines. The fourth criterion is fulfilled upon careful examination of the child's presenting signs and symptoms. In a review of 24 adult patients with ACTH-producing phaeochromocytomas, most of the patients presented with severe symptoms of Cushing's syndrome, hypertension, hyperglycaemia and severe hypokalaemia (9). In accordance with these features, our case presented with hypertension, hyperglycaemia and glycosuria, all of which resolved following unilateral adrenalectomy. Hypokalaemia in the ectopic ACTH syndrome is associated with a higher rate of cortisol production. Given the proposition that our child had mild or subclinical Cushing's syndrome, and therefore possibly only intermittent or short-term hypercortisolism, this could explain why he did not present with hypokalaemia. Paediatric Cushing's syndrome is often unrecognized by clinicians, perhaps due to the rarity and variable clinical phenotype, particularly in mild cases. The child's symptoms of catecholamine excess subsided post-adrenalectomy. Similarly, his hyperglycaemia, glycosuria and alteration in body composition, which suggested http://www.selleckchem.com/products/GDC-0449.html subclinical Cushing's syndrome, also subsided post-operatively. The final criterion is met through normalization of ACTH levels post-operatively. The first ACTH level was taken post-operatively, and was low/suppressed at