Endocrine Abstracts

A 64-year old female presented to the emergency department with a three week history of worsening shortness of breath, palpitations and fatigue. In the preceding 5 years, she was reviewed by various specialists for diarrhoea, nausea, palpitations, shortness of breath, weight loss and fatigue. The colorectal team organised a CT chest abdomen pelvis (CTCAP) in 2020, which reported multiple mesenteric, para-aortic and mediastinal lymphadenopathy. No masses were identified. Her chronic diarrhoea was thought to be attributed to bile acid malabsorption. She was referred to Haematology to investigate for a possible lymphoproliferative disorder. Immunophenotyping and bloods were generally unremarkable. Biopsy of a mesenteric lymph node was not successful. It was assumed that the lymphadenopathy was secondary to autoimmune disease as she is known to have Sjogren’s disease. She recently underwent an aortic, mitral and tricuspid valve replacement for severe regurgitation and is on diuretics for heart failure. She also was diagnosed with recurrent atrial flutter. During this admission, she was in atrial flutter and had pitting oedema up to her sacrum. She was treated with rate control and a furosemide infusion. Echocardiogram showed reduced longitudinal function of the right ventricle but was otherwise unremarkable. A repeat CTCAP was performed due to ongoing weight loss. Multiple lymph nodes above and below the diaphragm were identified, similar to previous scans. However, a new finding of a soft tissue mass in the central mesentery was also reported. The mass was biopsied via ultrasound guidance. Shortly after the biopsy, the patient became unwell with vomiting, tremors, and went into hypotensive shock. She was transferred to ITU for inotropic support. CT angiogram did not identify any signs of active haemorrhage. However, the development of multiple nodules within the lung bilaterally concerning for pulmonary metastases was reported. Histology came as back as a grade 1 well differentiated neuroendocrine tumour. She was then started on an octreotide infusion, as well as dexamethasone and cyproheptadine. The 24-hour urine 5-HIAA result is pending. This case demonstrates that carcinoid syndrome should be considered in patients who have non-specific symptoms and valvular heart disease, as 50% of patients with carcinoid syndrome have carcinoid heart disease. Furthermore, if carcinoid is suspected by a raised urine 5-HIAA, treatment with somatostatin analogues prior to biopsy can help reduce to risk of precipitating a carcinoid crisis.