The ISI did not differ significantly among the various phenotypes of PCOS. In comparison with hyperandrogenemia, chronic anovulation, and PCOM, obesity was the dominant risk factor in determining insulin resistance in women with PCOS.

A 68-year-old woman was sent to the emergency department (ED) because of alterations in her level of consciousness. The patient had polydipsia and experienced a weight loss of about 6 kg, which was associated with progressive general weakness over a period of several months. Intermittent diaphoresis and palpitation with occasional headache were also noted. She had no known underlying systemic disease, such as hypertension or cardiac dysrhythmia. She denied taking any medication. She smoked 0.2 packs per day for 3 years, but denied taking either alcohol or illicit drugs. She denied a family history of diabetes mellitus (DM) or any familial diseases.At the ED, the patient's body mass index was underweight at 17.6 kg/m 2 . Her body temperature was 38.0°C, with a blood pressure of 199/118 mmHg, pulse rate 129 beats per minute, and respiratory rate 18 breaths per minute. The oxygen saturation was 93 % while she was breathing in ambient air. The laboratory data showed a newly-diagnosed DM complicated with a hyperosmolar hyperglycemic state (serum glucose at 1836 mg/dl, serum sodium 124 mmol/l, hemoglobin A1 C 14.4 %, and effective osmolality 350 mOsm/kg). After adequate hydration, insulin therapy and appropriate antibiotics for suspected aspiration pneumonia, the patient's blood sugar improved and the fever subsided. During hospitalization, blood pressures were 100-120/60-70 mmHg without any sign of hypertension or signs suggestive of orthostatic changes.However, on the 20th hospital day, the patient had a second bout of fever with sepsis-like presentation (high fever 39.3°C, tachycardia 110 beats per minute, tachypnea, but without leukocytosis) that was refractory to antibiotic therapy. Abdominal sonography was performed to search for the infection focus, which revealed an intraabdominal tumor near the liver and kidney. A subsequent computed tomography confirmed a 4-cm solid heterogeneous mass lesion in the right adrenal gland (Fig. 1a). Based on the patient's clinical presentations (markedly elevated blood pressure at ED, history of intermittent palpitation, and unusual fever), a pheochromocytoma was highly likely. Collection of 24-h urine for catecholamine and vanillylmandelic acid (VMA) levels showed the isolated elevation of epinephrine levels. Repeated collection of urinary examination for catecholamines and VMA levels were performed after the patient was free from her acute illness showed similar results (Table 1). Pre-operative treatment with a-and b-blockade treatment were given to the patient, and she underwent uneventful laparoscopic right adrenalectomy. The pathological examination confirmed our diagnosis of pheochromocytoma (Fig. 1b). The patient remained symptom-free with normal urinary catecholamines excretion after 6 months of post-operative follow-up. Her DM is presently under good glycemic control (hemoglobin A1 C 6.1 %) using an oral antidiabetic agent (metformin 250 mg daily). Moreover, she gradually gained weight to a body mass index of 23.4 kg/m 2 . Pheochromocytoma is a rare catecholamine-produc...