Iʼm Flushing While Iʼm Flushing: Primary Ovarian Carcinoid Tumor as a Rare Cause of Chronic Diarrhea

Abstract

69 year old female with no significant past medical history presented to clinic for a second opinion with a chief complaint of chronic diarrhea. Her symptoms started about 3 months prior with the typical pattern being 2-4 watery stools throughout the day and occasionally at night when sleeping. She denied, hematochezia, melena, weight loss, sick contacts, travel outside the country, fevers, lymphadenopathy, new medications or association with foods. She had an esophagogastroduodenoscopy (EGD) and colonoscopy 1 month with another physician which was normal. Duodenal biopsies were negative. There was no evidence of Irritable bowel disease, biopsies were negative for any evidence of colitis. No masses or polyps found. Celiac panels and stools studies were negative. Along with the diarrhea she also complained of intermittently getting a sensation of flushing, particularly in her face. Her last menstrual cycle was in her 50s, and she denied vaginal bleeding. Her physical exam was notable for her cheeks with a reddish hue and a palpable abdominal mass below the umbilicus, without evidence of ascites. A subsequent Computerized tomography (CT) scan of her abdomen and pelvis showed an 11.4x13.7x9.3cm mass near the uterus. 5-HIAA and Chromogranin A levels were both elevated at 1568mg and 72U/L, respectively. An Octreotide scan showed uptake in a large mass in the pelvis with no uptake in lung, liver or bowel. Subsequently, her right ovary was surgically removed and pathology reports came back as well differentiated neuroendocrine tumor of the ovary. After the surgery her Serotonin and chromogranin levels came down to normal and her flushing and diarrhea symptoms resolved. Follow up one year later revealed no diarrhea and flushing and her Chromogranin A level was normal. Primary carcinoid tumors confined to the ovary are rare and account for < 1% of all carcinoid tumors, and less than 0.1% of all ovarian neoplasms. Carcinoid syndrome (facial flushing, diarrhea, bronchospasm, edema) has been seen to occur in one third of patients with ovarian carcinoid tumors. This occurs by hormones released directly into the systemic circulation, bypassing deactivation by the liver. The prognosis remains excellent among patients with primary carcinoids confined to the ovary at the time of presentation. The primary treatment is removal of the tumor. Although rare, primary ovarian carcinoid tumor should be considered in women with symptoms of chronic diarrhea and flushing.