Case Presentation:
A 67‐year‐old man presented to the emergency room with progressive bilateral lower extremity edema for 3 weeks. He denied any dyspnea, oliguria, or chest pain. His medical history was significant for an intestinal carcinoid tumor status posthemicolectomy 10 years ago. On exam, he had moderate jugular venous distension, significant bilateral lower extremity edema, right‐sided hydrocele, and mild ascites. Cardiopulmonary exam revealed a new 3/6 tricuspid holosystolic murmur. Routine labs and chest X‐ray were normal. The patient was admitted to the hospitalist service for further workup with a preliminary diagnosis of right‐sided heart failure (HF). An echocardiogram was done to assess for valvular dysfunction, which demonstrated severe tricuspid regurgitation (TR). The etiologies for his TR included pulmonary hypertension, right ventricular dysfunction, and valvular pathologies secondary to infective endocarditis (IE), rheumatic fever, connective tissue disorders, and carcinoid syndrome (CS). The patient had no predisposing factors for cor pulmonale or IE. Given our suspicion of recurrence of his carcinoid tumor, we ordered an abdominal ultrasound, which showed hyperechoic liver lesions suspicious for metastases. A confirmatory somatostatin receptor scan revealed increased hepatic tracer uptake consistent with metastatic carcinoid. Urine 5‐hydroxyindoleacetic acid and serum serotonin levels were markedly elevated. Further inquiry revealed symptoms of diarrhea and flushing episodes over the past year. The patient was diagnosed with CS and carcinoid heart disease (CHD) secondary to metastatic carcinoid of the liver. Symptoms responded to a combination of diuretics, angiotensin‐converting enzyme inhibitors, and weekly octreotide injections. He was discharged with plans for follow‐up radiation, chemotherapy, and valve replacement surgery.
Discussion:
CS and CHD are rare among the general population and are typically seen in patients with hepatic metastasis of gastrointestinal carcinoid. Despite surgery, patients with intestinal carcinoid lesions greater than 2 cm have a high risk of recurrence and metastasis. Hence, it was appropriate to evaluate for CS and CHD in our patient. With the development of hepatic metastasis, high concentrations of vasoactive tumor products exceed the hepatic capacity for degradation and enter the IVC. This initiates the pathologic processes that culminate in TR and right HF. Management includes use of somastatin analogues and tumor‐debulking techniques to diminish symptoms of CS, whereas diuretics and valve replacement surgery are used to treat the pathologic valves.
Conclusions:
HF is a leading cause of hospital admissions, and hospitalists are routinely involved in the management of HF patients. This case focuses on carcinoid heart disease as an uncommon cause of right‐sided HF. It is vital for hospitalists to consider alternative HF etiologies in patients without the usual risk factors and utilize critical reasoning to ascertain the correct diagnosis and facilitate appropriate management.
Author Disclosure:
L. Swaminathan, none; D. Kannabhiran, none; R. Daniel, none.