Duodenal Carcinoid with Cystic Hepatic Metastasis Presenting with Severe Anemia and Heart Failure

Abstract

Introduction: Carcinoid tumours are neoplasms of neuroendocrine cells with varying symptoms and malignant potential. Cystic hepatic metastasis secondary to carcinoids is a rare entity. There are very few reports in literature (around four as of date) and all have been in relation to ileal carcinoid or post chemotherapy. Most of the carcinoids present with diarrhoea, flushing, pruritis. Severe anemia as presenting symptom is rare. Case report: Herein we describe a 66 year old gentleman who presented with severe anemia and heart failure. An OGD (Oesophago gastro duodenal endoscopy) done as part of anemia work-up revealed multiple, duodenal, centrally umbilicated nodules. Histopathology and special stains (chromogranin & synaptophysin) confirmed it to be Grade 1 Neuroendocrine tumour (carcinoid) with a Ki-67 index of less than 2%. CECT abdomen showed two small cystic lesions, the largest one measuring 2x3cms. Anemia was corrected and patient improved symptomatically. He was placed on conservative management for Neuroendocrine tumours and is on regular follow up. Discussion: In this case patient presented with severe anemia and heart failure. He had no other symptoms like flushing, diarrhoea. The rarity of this case is the presence of cystic hepatic metastasis and presentation with severe anemia. This is the first case reported in which a duodenal carcinoid is diagnosed during the workup for anemia. Here another interesting and rare feature is the presence of cystic hepatic metastasis which is quite unusual. Case report: A 66 year old male, known case of CVA not on treatment, hypertensive on treatment admitted with history of progressive easy fatigability, progressive bilateral lower limb swelling, decreased appetite for 15 days. Patient denied history of diarrhea, vomiting, melena or hematochezia, diabetes, hypertension or cardiac problems .Physical examination revealed pallor, bilateral pitting pedal oedema, raised JVP, with pansystolic murmur at tricuspid area, S3 with bilateral basal crepitations and rhonchi with tender right hypochondrium. His initial workup revealed hemoglobin of 4.3gm/dl and peripheral blood smear showed microcytic hypochromic anaemia. Liver and kidney functions were within normal limits with a serum albumin of 3.4mg/dl. 2D ECHO revealed dilated RA, RV with a severe tricuspid regurgitation (TR) with PASP of 70 mmHg. LVEF 56%,No RWMA, mild MR & AR. Oesophago-gastro duodenoscopy(OGD) revealed multiple duodenal nodules with central umbilication in D1,D2,D3 with largest measuring 2x3 cm(?Carcinoid) and was biopsied for histopathological examination(HPE) (fig 1). Contrast enhanced computerised tomography(CE-CT) thorax and abdomen revealed enlarged liver(15.5cm) with two well defined non enhancing cystic lesions in segments 4A of liver (measuring 36x31x32 mm and 8x9x4 mm) and pyloric and duodenal wall thickening suggesting a possibility neoplastic etiology(fig 2). HPE (Fig 3) revealed well differentiated neuroendocrine tumor (WHO grade1) with EMA, synaptophysin, chromogranin positive and a Ki-67 ind...