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This 64-year-old man presented with a four-month history of episodic wheezing and diarrhea. His wife said that when they dinedtogether, she noticed that his cheeks would become flushed and remain so for about an hour after the meal. The patient was symptom-free during thesetimes.
In addition to his facial flushing, this patient had facial telangiectases, an enlarged liver, and striking murmurs of tricuspidregurgitation and pulmonic stenosis. A liver biopsy specimen showed a neuroendocrine tumor with characteristics indicative of a midgutcarcinoid.
This case illustrates several important clinical features of the carcinoid syndrome:
1) right-sided valvular heart lesions are characteristic and offer an immediate clue to the diagnosis;
2) with few exceptions, hepatic metastases have already occurred by the time flushing first appears;
3) the flushes can vary considerably in color, frequency, duration, distribution, and symptomatology;
4) eating provokes the flushing in some patients.
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