WHEEZING: A WHISTLEBLOWER FOR PULMONARY CARCINOID

TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: Dyspnea and wheezing are the common complaints encountered in the primary care setting. Primary care physicians should keep the common diseases in their minds while also keeping the rare diseases in their differential diagnosis. The incidence of pulmonary carcinoid is around 5 cases/100,000. Carcinoid tumors comprise 2% of all lung tumors. (1) Hemoptysis and cough are the most common symptoms associated with pulmonary carcinoid. We report a case of a patient who presented with refractory wheezing. CASE PRESENTATION: A 36-year-old lady with a history of asthma presented with worsening dyspnea and wheezing for the past one month. She had no other complaints. She was frequently using an albuterol inhaler; however, she had no benefit. Physical examination was unremarkable except for wheezing. She was prescribed a corticosteroid and salmeterol inhaler. She denied resolution of wheezing and dyspnea despite using inhalers for one month. On her follow-up visit, CXR was performed, which was remarkable for the left lower lobe lung mass. CT Chest showed 4x5 cm mass in the left lower lobe of the lung (fig 1). PET CT scan was significant for Gallium-68 dotatate uptake in the left lung lower lobe evident for somatostatin-rich carcinoid tumor (fig 2). 24h urinary 5-hydroxyindoleacetic Acid (5-HIAA) was unremarkable. Bronchoscopy demonstrated a large occlusive left lower lobe mass. The bronchial biopsy was remarkable for typical carcinoid. She underwent left lower lobectomy with mediastinal lymph node dissection. Lung biopsy showed low-grade typical carcinoid (fig 3). Mediastinal lymph nodes were negative for any metastasis. She had an uneventful stay at the hospital and was discharged. She had a resolution of wheezing and dyspnea at a follow-up visit. DISCUSSION: Pulmonary carcinoid is a rare disease. Typical carcinoids are more prevalent than atypical carcinoids. Typical carcinoids are low-grade tumors, while atypical carcinoids are high-grade tumors (2). We hypothesize that our patient had wheezing, and dyspnea due to the mass effect of carcinoid tumor. Centrally located tumors present with hemoptysis, cough, and recurrent respiratory tract infections while peripherally located tumors are mostly silent. Pulmonary Carcinoid is diagnosed by bronchoscopy. Treatment of pulmonary carcinoid is primarily by surgery (3). Surgical modalities include pneumonectomy, lobectomy, segmentectomy, and wedge resection. Chemotherapy and radiotherapy are the treatment of choice in metastasis. CONCLUSIONS: Clinicians should utilize imaging studies to rule out any obstructive lung lesion in patients with refractory wheezing and dyspnea. REFERENCE #1: Cardillo G, Sera F, Di Martino M, et al. Bronchial carcinoid tumors: nodal status and long-term survival after resection. Ann Thorac Surg. 2004;77(5):1781-1785. doi:10.1016/j.athoracsur.2003.10.089 REFERENCE #2: Davila DG, Dunn WF, Tazelaar HD, Pairolero PC. Bronchial carcinoid tumors. Mayo Clin Proc. 1993;68(8):795-803. doi:10.1016/s0025-6196(12)60641-7 REFERENCE #3: Jeung MY, Gasser B, Gangi A, et al. Bronchial carcinoid tumors of the thorax: spectrum of radiologic findings. Radiographics. 2002;22(2):351-365. doi:10.1148/radiographics.22.2.g02mr01351 DISCLOSURES: No relevant relationships by Muhammad Aamir, source=Web Response No relevant relationships by Ali AKRAM, source=Web Response No relevant relationships by Muhammad Ibrar Islam, source=Web Response No relevant relationships by Jeet Lund, source=Web Response No relevant relationships by Junaid mir, source=Web Response No relevant relationships by Ateeb Ur Rahman, source=Web Response