Carcinoid Crisis Induced by External Manipulation of Liver Metastasis

To the Editor: We recently had a challenging experience that we would like to report: a 62-year-old woman with a 13-year history of carcinoid syndrome presented with 2 hours of abdominal pain. Her past medical history included liver metastatic carcinoid tumor from the small bowel, biliary colic, abdominal pain, and diarrhea that responded to octreotide; she also was diagnosed with right heart failure and tricuspid valve regurgitation. On her current presentation, she awoke with acute, knife-like, pain, located in the right upper quadrant and epigastrium, radiating to the back. This was relieved by lying on her abdomen. She also had a fever, chills, and nausea. Her medications included coumadin, Lasix (Aventis Pharmaceuticals, Inc., Kansas City, MO), spironolactone, and Sandostatin (Sandoz, East Hanover, NJ). Physical exam revealed a temperature of 101°F, with an irregular heart rate of 100 beats/min, a normal respiratory rate, and a blood pressure of 100/62. A tricuspid regurgitation murmur was noted. Her abdomen was soft; a 10 × 4-cm, firm, slightly tender right upper quadrant mass was noted. Laboratory study revealed a white blood cell count of 17,900/mm3; hemoglobin, 10.1 g/dL; alkaline phosphatase, 132 U/L (normal, 38–126 U/L); aspartate transaminase, 113 U/L; international normalized ratio, 4.05; and bilirubin, 1.2 mg/dL, with no electrolyte abnormalities or elevated pancreatic enzymes. An ultrasound showed gallstones but did not reveal an ultrasonic Murphy sign or intratumor bleeding. Shortly after the ultrasound, the patient became diaphoretic and clammy, her extremities were cold and pale, but her trunk was warm. Facial flushing was noted. No blood pressure could be obtained, but her heart rate was 72 beats/min. Her hypotension did not respond to fluids and dopamine. An octreotide 200-μg intravenous push was used successfully to correct her refractory hypotension. Other causes of hypotension (sepsis, cardiac) were ruled out during hospitalization. Her 5-hydroxyindoleacetic acid level was consistently high after 3 days of the acute episode. The patient was discharged home after prolonged recovery. We think that the hypotension after the ultrasound is consistent with carcinoid crisis and that the external manipulation (rubbing ultrasound probe against the tumor) was the cause for this crisis. Multiple causes have been implicated as precipitating factors for a crisis, including percutaneous fine needle biopsy, 1 surgery, anesthesia, 2 transesophageal echo, 3 and compression of metastatic carcinoid disease of the breast during mammography. 4 Our case is unique as it was induced by external manipulation during the ultrasound study. The management of the crisis includes fluid expansion and the use of 50 μg of intravenous octreotide 5,6 (Sandostatin; Sandoz). Although the dosage used in those reports was less than the one we used, those patients were not undergoing chronic octreotide therapy. It is important to avoid administrating adrenergic catecholamine, as this may stimulate further hormonal release and paradoxically worsen the hypotension. This case adds a new precipitating factor to the cause of carcinoid crisis. Houssam Al Kharrat, M.D. Howard Taubin, M.D.