Abstract
SummaryA 63-year-old female presented to hospital with progressive exertional dyspnoea over a 6-month period. In the year preceding her admission, she reported an intercurrent history of abdominal pain, diarrhoea and weight loss. She was found to be hypoxic, the cause for which was initially unclear. A ventilation–perfusion scan identified a right-to-left shunt. Transoesophageal echocardiography (TOE) demonstrated a significant right-to-left intracardiac shunt through a patent foramen ovale (PFO); additionally severe tricuspid regurgitation was noted through a highly abnormal tricuspid valve. The findings were consistent with carcinoid heart disease with a haemodynamically significant shunt, resulting in profound systemic hypoxia. 24-h urinary 5-hydroxyindoleacetic acid (5-HIAA) and imaging were consistent with a terminal ileal primary carcinoid cancer with hepatic metastasis. Liver biopsy confirmed a tissue diagnosis. The patient was commenced on medical therapy for carcinoid syndrome. She subsequently passed away while undergoing anaesthetic induction for valvular surgery to treat her carcinoid heart disease and PFO.
Highlights
Exertional breathlessness is a common presenting complaint in acute medicine
Persistent hypoxia was further investigated with a ventilation–perfusion (VQ) nuclear scan, which showed no evidence of perfusion defect to suggest thromboembolic disease, but did confirm the presence of a large right-to-left shunt
Carcinoid syndrome is a clinical manifestation of a welldifferentiated neuroendocrine tumour (NET)
Summary
A 63-year-old female presented to hospital with progressive exertional dyspnoea over a 6-month period. In the year preceding her admission, she reported an intercurrent history of abdominal pain, diarrhoea and weight loss. She was found to be hypoxic, the cause for which was initially unclear. Transoesophageal echocardiography (TOE) demonstrated a significant rightto-left intracardiac shunt through a patent foramen ovale (PFO); severe tricuspid regurgitation was noted through a highly abnormal tricuspid valve. The findings were consistent with carcinoid heart disease with a haemodynamically significant shunt, resulting in profound systemic hypoxia. The patient was commenced on medical therapy for carcinoid syndrome.
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