SUN-925 Carcinoid: A Crisis in the Upside Down

Unrecognized carcinoid tumors can rarely present as a life-threatening condition known as carcinoid ‘crisis’ which typically presents as significant but transient hypotension if there is no appropriate preventive treatment. Somatostatin analogs such as Octreotide are agents of choice to avoid such crises. However, there is minimal literature and a lack of guidelines regarding the management of an active, labile carcinoid crisis in patients exhibiting both hypotension and hypertension, as will be presented here. Case: A 76-year-old female with end-stage renal disease, status post kidney transplant on immunosuppressants, who was initially admitted for workup of hematuria. Abdominal CT revealed a bladder mass with various features concerning for malignancy and an incidental mesenteric mass, followed by bladder biopsy suggestive of neoplasm. The patient was taken to the OR where she first underwent resection of the bladder mass with subsequent proceeding to the removal of the mesenteric mass. Within minutes of manipulation of the mass, the patient became significantly hypotensive with a mild response to fluid resuscitation, requiring vasopressors. A frozen section suggested the possibility of a neuroendocrine tumor. Given concerns of carcinoid crisis the patient was started on Octreotide infusion achieving some degree of hemodynamic stabilization but soon developed extremely labile blood pressure with rapidly alternating hypotension (SBP <60mmHg) and hypertension (SBP >200mmgHg). During hypotensive episodes, the aid of adjunctive beta-adrenergic agents was required, while the doses for the Octreotide infusion were as high as 200mcg/hr. Initial Endocrinologic workup revealed a Chromogranin A level 1,178 ng/mL (25 - 140 ng/mL), VIP <50 pg/mL (<75 pg/mL), 24 hr 5HIAA 23.5 (<=6.0 mg/24 h), Serotonin 2,334 ng/mL (56 - 244 ng/mL) consistent with carcinoid. Repeat Serotonin levels 5 days after octreotide infusion was 674 ng/mL. The patient was successfully weaned from vasopressors but required continuation of Octreotide for additional 5 days due to intermittent episodes of hypotension. Carcinoid crisis is a life-threatening condition associated with hypotension, and less commonly hypertension, from the release of vasoactive agents from tumor manipulation. Preparation with Octreotide before any manipulation or anesthesia is recommended to avoid a carcinoid crisis. However, if a crisis develops management is mainly with a continuous Octreotide infusion. The use of beta-adrenergic agents is debated, due to a possible “paradoxical effect” which could further worsen hypotension. Others argue that there is a role in preventing prolonged episodes of hypotension. In this case, it was required high doses and the infusion was needed for 5 days, probably related to the presence of ESRD which could have prolonged the bioavailability of the vasoactive agents.